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Ignatius EH, Rimal B, Panthi CM, Belz DC, Lippincott CK, Deck DH, Serio AW, Lamichhane G. Efficacies of omadacycline + amikacin + imipenem and an all-oral regimen omadacycline + clofazimine + linezolid in a mouse model of M. abscessus lung disease. mSphere 2024:e0038124. [PMID: 38980071 DOI: 10.1128/msphere.00381-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/26/2024] [Indexed: 07/10/2024] Open
Abstract
Treatment outcomes for Mycobacteroides abscessus (Mab, also known as Mycobacterium abscessus) disease are still unsatisfactory, mainly due to issues with drug toxicity, tolerability, and efficacy. Treating Mab disease is challenging due to its high baseline antibiotic resistance, initial requirement for intravenous therapy, and poor medication tolerance. Omadacycline, a new tetracycline, is active against Mab. Since any new antibiotic effective against Mab is expected to be used in combination with other antibiotics, we evaluated the efficacy of two triple-drug combinations comprising omadacycline, omadacycline + amikacin + imipenem, and omadacycline + clofazimine + linezolid against two contemporary Mab clinical isolates in a mouse model of Mab lung disease. Antibiotic administration was initiated 1-week post-infection and was given daily, with Mab burden in the lungs at treatment completion serving as the endpoint. Omadacycline alone moderately reduced Mab levels and maintained better health in mice compared to untreated ones, which typically suffered from the infection. The omadacycline + clofazimine + linezolid combination showed immediate bactericidal activity and enhanced efficacy over 6 weeks, particularly against the more resistant strain (M9507). However, the clofazimine + linezolid combination lacked early bactericidal activity. When combined with amikacin and imipenem, omadacycline did not improve the regimen's effectiveness over 4 weeks of treatment. Our study showed that omadacycline + clofazimine + linezolid exhibited significant bactericidal activity over an extended treatment duration. However, adding omadacycline to amikacin and imipenem did not improve regimen effectiveness against the evaluated clinical isolates within 4 weeks. Further research in Mab disease patients is needed to determine the most effective omadacycline-containing regimen.IMPORTANCEMycobacteroides abscessus is a common environmental bacterium that causes infections in people with compromised lung function, including those with bronchiectasis, cystic fibrosis, chronic obstructive pulmonary disease, and weakened immune systems, especially among older individuals. Treating M. abscessus disease is challenging due to the limited effectiveness and toxicity of current antibiotics, which often require prolonged use. Omadacycline, a new antibiotic, shows promise against M. abscessus. Using a mouse model that mimics M. abscessus disease in humans, we studied the effectiveness of including omadacycline with recommended antibiotics. Adding omadacycline to clofazimine and linezolid significantly improved treatment outcomes, rapidly clearing the bacteria from the lungs and maintaining effectiveness throughout. This oral combination is convenient for patients. However, adding omadacycline to amikacin and imipenem did not improve treatment effectiveness within 4 weeks. Further study with M. abscessus patients is necessary to optimize omadacycline-based treatment strategies for this disease.
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Affiliation(s)
- Elisa H Ignatius
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Nontuberculous Mycobacteria and Bronchiectasis, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Binayak Rimal
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chandra M Panthi
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel C Belz
- Center for Nontuberculous Mycobacteria and Bronchiectasis, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher K Lippincott
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Nontuberculous Mycobacteria and Bronchiectasis, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel H Deck
- Paratek Pharmaceuticals Inc., King of Prussia, Pennsylvania, USA
| | - Alisa W Serio
- Paratek Pharmaceuticals Inc., King of Prussia, Pennsylvania, USA
| | - Gyanu Lamichhane
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Nontuberculous Mycobacteria and Bronchiectasis, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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2
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Lyons MA, Obregon-Henao A, Ramey ME, Bauman AA, Pauly S, Rossmassler K, Reid J, Karger B, Walter ND, Robertson GT. Use of multiple pharmacodynamic measures to deconstruct the Nix-TB regimen in a short-course murine model of tuberculosis. Antimicrob Agents Chemother 2024; 68:e0101023. [PMID: 38501805 PMCID: PMC11064538 DOI: 10.1128/aac.01010-23] [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: 08/02/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024] Open
Abstract
A major challenge for tuberculosis (TB) drug development is to prioritize promising combination regimens from a large and growing number of possibilities. This includes demonstrating individual drug contributions to the activity of higher-order combinations. A BALB/c mouse TB infection model was used to evaluate the contributions of each drug and pairwise combination in the clinically relevant Nix-TB regimen [bedaquiline-pretomanid-linezolid (BPaL)] during the first 3 weeks of treatment at human equivalent doses. The rRNA synthesis (RS) ratio, an exploratory pharmacodynamic (PD) marker of ongoing Mycobacterium tuberculosis rRNA synthesis, together with solid culture CFU counts and liquid culture time to positivity (TTP) were used as PD markers of treatment response in lung tissue; and their time-course profiles were mathematically modeled using rate equations with pharmacologically interpretable parameters. Antimicrobial interactions were quantified using Bliss independence and Isserlis formulas. Subadditive (or antagonistic) and additive effects on bacillary load, assessed by CFU and TTP, were found for bedaquiline-pretomanid and linezolid-containing pairs, respectively. In contrast, subadditive and additive effects on rRNA synthesis were found for pretomanid-linezolid and bedaquiline-containing pairs, respectively. Additionally, accurate predictions of the response to BPaL for all three PD markers were made using only the single-drug and pairwise effects together with an assumption of negligible three-way drug interactions. The results represent an experimental and PD modeling approach aimed at reducing combinatorial complexity and improving the cost-effectiveness of in vivo systems for preclinical TB regimen development.
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Affiliation(s)
- M. A. Lyons
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - A. Obregon-Henao
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - M. E. Ramey
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - A. A. Bauman
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - S. Pauly
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - K. Rossmassler
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - J. Reid
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - B. Karger
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - N. D. Walter
- 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
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - G. T. Robertson
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
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3
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Diacon AH, Barry CE, Carlton A, Chen RY, Davies M, de Jager V, Fletcher K, Koh GCKW, Kontsevaya I, Heyckendorf J, Lange C, Reimann M, Penman SL, Scott R, Maher-Edwards G, Tiberi S, Vlasakakis G, Upton CM, Aguirre DB. A first-in-class leucyl-tRNA synthetase inhibitor, ganfeborole, for rifampicin-susceptible tuberculosis: a phase 2a open-label, randomized trial. Nat Med 2024; 30:896-904. [PMID: 38365949 PMCID: PMC10957473 DOI: 10.1038/s41591-024-02829-7] [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: 06/08/2023] [Accepted: 01/22/2024] [Indexed: 02/18/2024]
Abstract
New tuberculosis treatments are needed to address drug resistance, lengthy treatment duration and adverse reactions of available agents. GSK3036656 (ganfeborole) is a first-in-class benzoxaborole inhibiting the Mycobacterium tuberculosis leucyl-tRNA synthetase. Here, in this phase 2a, single-center, open-label, randomized trial, we assessed early bactericidal activity (primary objective) and safety and pharmacokinetics (secondary objectives) of ganfeborole in participants with untreated, rifampicin-susceptible pulmonary tuberculosis. Overall, 75 males were treated with ganfeborole (1/5/15/30 mg) or standard of care (Rifafour e-275 or generic alternative) once daily for 14 days. We observed numerical reductions in daily sputum-derived colony-forming units from baseline in participants receiving 5, 15 and 30 mg once daily but not those receiving 1 mg ganfeborole. Adverse event rates were comparable across groups; all events were grade 1 or 2. In a participant subset, post hoc exploratory computational analysis of 18F-fluorodeoxyglucose positron emission tomography/computed tomography findings showed measurable treatment responses across several lesion types in those receiving ganfeborole 30 mg at day 14. Analysis of whole-blood transcriptional treatment response to ganfeborole 30 mg at day 14 revealed a strong association with neutrophil-dominated transcriptional modules. The demonstrated bactericidal activity and acceptable safety profile suggest that ganfeborole is a potential candidate for combination treatment of pulmonary tuberculosis.ClinicalTrials.gov identifier: NCT03557281 .
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Affiliation(s)
| | - Clifton E Barry
- National Institutes of Health, Bethesda, MD, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Ray Y Chen
- National Institutes of Health, Bethesda, MD, USA
| | | | | | | | | | - Irina Kontsevaya
- Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Borstel, Germany
- Respiratory Medicine and Infectious Diseases, University of Lübeck, Lübeck, Germany
- Research Center Borstel, Leibniz Lung Center, German Center for Infection Research, Borstel and the University of Lübeck, Lübeck, Germany
- Imperial College London, London, UK
| | - Jan Heyckendorf
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Christoph Lange
- Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Borstel, Germany
- Respiratory Medicine and Infectious Diseases, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Maja Reimann
- Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Borstel, Germany
- Respiratory Medicine and Infectious Diseases, University of Lübeck, Lübeck, Germany
| | | | | | | | - Simon Tiberi
- GSK, London, UK
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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4
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Lyons MA, Obregon-Henao A, Ramey ME, Bauman AA, Pauly S, Rossmassler K, Reid J, Karger B, Walter ND, Robertson GT. Use of Multiple Pharmacodynamic Measures to Deconstruct the Nix-TB Regimen in a Short-Course Murine Model of Tuberculosis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.11.08.566205. [PMID: 37986955 PMCID: PMC10659381 DOI: 10.1101/2023.11.08.566205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
A major challenge for tuberculosis (TB) drug development is to prioritize promising combination regimens from a large and growing number of possibilities. This includes demonstrating individual drug contributions to the activity of higher-order combinations. A BALB/c mouse TB infection model was used to evaluate the contributions of each drug and pairwise combination in the clinically relevant Nix-TB regimen (bedaquiline-pretomanid-linezolid [BPaL]) during the first three weeks of treatment at human equivalent doses. RS ratio, an exploratory pharmacodynamic (PD) marker of ongoing Mycobacterium tuberculosis rRNA synthesis, to-gether with solid culture CFU and liquid culture time to positivity (TTP) were used as PD markers of treatment response in lung tissue; and their time course profiles were mathematically modeled using rate equations with pharmacologically interpretable parameters. Antimicrobial interactions were quantified using Bliss independence and Isserlis formulas. Subadditive (or antagonistic) and additive effects on bacillary load, assessed by CFU and TTP, were found for bedaquiline-pretomanid and linezolid-containing pairs, respectively. In contrast, subadditive and additive effects on rRNA synthesis were found for pretomanid-linezolid and bedaquiline-containing pairs, respectively. Additionally, accurate predictions of the response to BPaL for all three PD markers were made using only the single-drug and pairwise effects together with an assumption of negligible three-way drug interactions. The results represent an experimental and PD modeling approach aimed at reducing combinatorial complexity and improving the cost-effectiveness of in vivo systems for preclinical TB regimen development.
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5
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Ayoun Alsoud R, Svensson RJ, Svensson EM, Gillespie SH, Boeree MJ, Diacon AH, Dawson R, Aarnoutse RE, Simonsson USH. Combined quantitative tuberculosis biomarker model for time-to-positivity and colony forming unit to support tuberculosis drug development. Front Pharmacol 2023; 14:1067295. [PMID: 36998606 PMCID: PMC10043246 DOI: 10.3389/fphar.2023.1067295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
Biomarkers are quantifiable characteristics of biological processes. In Mycobacterium tuberculosis, common biomarkers used in clinical drug development are colony forming unit (CFU) and time-to-positivity (TTP) from sputum samples. This analysis aimed to develop a combined quantitative tuberculosis biomarker model for CFU and TTP biomarkers for assessing drug efficacy in early bactericidal activity studies. Daily CFU and TTP observations in 83 previously patients with uncomplicated pulmonary tuberculosis after 7 days of different rifampicin monotherapy treatments (10–40 mg/kg) from the HIGHRIF1 study were included in this analysis. The combined quantitative tuberculosis biomarker model employed the Multistate Tuberculosis Pharmacometric model linked to a rifampicin pharmacokinetic model in order to determine drug exposure-response relationships on three bacterial sub-states using both the CFU and TTP data simultaneously. CFU was predicted from the MTP model and TTP was predicted through a time-to-event approach from the TTP model, which was linked to the MTP model through the transfer of all bacterial sub-states in the MTP model to a one bacterial TTP model. The non-linear CFU-TTP relationship over time was well predicted by the final model. The combined quantitative tuberculosis biomarker model provides an efficient approach for assessing drug efficacy informed by both CFU and TTP data in early bactericidal activity studies and to describe the relationship between CFU and TTP over time.
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Affiliation(s)
- Rami Ayoun Alsoud
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Robin J. Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Elin M. Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Stephen H. Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Martin J. Boeree
- Department of Lung Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - Rob E. Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ulrika S. H. Simonsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
- *Correspondence: Ulrika S. H. Simonsson,
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6
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Verboven L, Callens S, Black J, Maartens G, Dooley KE, Potgieter S, Cartuyvels R, Laukens K, Warren RM, Van Rie A. A machine-learning based model for automated recommendation of individualized treatment of rifampicin-resistant tuberculosis. RESEARCH SQUARE 2023:rs.3.rs-2525765. [PMID: 36824956 PMCID: PMC9949242 DOI: 10.21203/rs.3.rs-2525765/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background Rifampicin resistant tuberculosis remains a global health problem with almost half a million new cases annually. In high-income countries patients empirically start a standardized treatment regimen, followed by an individualized regimen guided by drug susceptibility test (DST) results. In most settings, DST information is not available or is limited to isoniazid and fluoroquinolones. Whole genome sequencing could more accurately guide individualized treatment as the full drug resistance profile is obtained with a single test. Whole genome sequencing has not reached its full potential for patient care, in part due to the complexity of translating a resistance profile into the most effective individualized regimen. Methods We developed a treatment recommender clinical decision support system (CDSS) and an accompanying web application for user-friendly recommendation of the optimal individualized treatment regimen to a clinician. Results Following expert stakeholder meetings and literature review, nine drug features and 14 treatment regimen features were identified and quantified. Using machine learning, a model was developed to predict the optimal treatment regimen based on a training set of 3895 treatment regimen-expert feedback pairs. The acceptability of the treatment recommender CDSS was assessed as part of a clinical trial and in a routine care setting. Within the clinical trial setting, all patients received the CDSS recommended treatment. In 8 of 20 cases, the initial recommendation was recomputed because of stock out, clinical contra-indication or toxicity. In routine care setting, physicians rejected the treatment recommendation in 7 out of 15 cases because it deviated from the national TB treatment guidelines. A survey indicated that the treatment recommender CDSS is easy to use and useful in clinical practice but requires digital infrastructure support and training. Conclusions Our findings suggest that global implementation of the novel treatment recommender CDSS holds the potential to improve treatment outcomes of rifampicin resistant tuberculosis.
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Affiliation(s)
| | | | - John Black
- University of Cape Town and Livingstone Hospital
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Peters JS, McIvor A, Papadopoulos AO, Masangana T, Gordhan BG, Waja Z, Otwombe K, Letutu M, Kamariza M, Sterling TR, Bertozzi CR, Martinson NA, Kana BD. Differentially culturable tubercle bacteria as a measure of tuberculosis treatment response. Front Cell Infect Microbiol 2023; 12:1064148. [PMID: 36710965 PMCID: PMC9877613 DOI: 10.3389/fcimb.2022.1064148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Routine efficacy assessments of new tuberculosis (TB) treatments include quantitative solid culture or routine liquid culture, which likely miss quantification of drug tolerant bacteria. To improve these assessments, comparative analyses using additional measures such as quantification of differentially culturable tubercle bacteria (DCTB) are required. Essential for enabling this is a comparative measure of TB treatment responses using routine solid and liquid culture with liquid limiting dilutions (LLDs) that detect DCTB in sputum. Methods We recruited treatment-naïve TB patients, with and without HIV-infection, and serially quantified their sputum for DCTB over the course of treatment. Results Serial sputum sampling in 73 individuals during their first 14 days of treatment demonstrated that clearance of DCTB was slower compared to routine solid culture. Treatment response appeared to be characterized by four patterns: (1) Classic bi-phasic bacterial clearance; (2) early non-responders with slower clearance; (3) paradoxical worsening with an increase in bacterial count upon treatment initiation; and (4) non-responders with no change in bacterial load. During treatment, LLDs displayed greater bacterial yield when compared with quantitative solid culture. Upon treatment completion, 74% [46/62] of specimens displayed residual DCTB and within this group, two recurrences were diagnosed. Residual DCTB upon treatment completion was associated with a higher proportion of MGIT culture, GeneXpert, and smear positivity at two months post treatment. No recurrences occurred in the group without residual DCTB. Discussion These data indicate that DCTB assays detect distinct subpopulations of organisms in sputum that are missed by routine solid and liquid culture, and offer important alternatives for efficacy assessments of new TB treatments. The residual DCTB observed upon treatment completion suggests that TB treatment does not always eliminate all bacterial populations, a finding that should be investigated in larger cohorts.
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Affiliation(s)
- Julian S. Peters
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amanda McIvor
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrea O. Papadopoulos
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tshepiso Masangana
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bhavna G. Gordhan
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Waja
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matebogo Letutu
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mireille Kamariza
- Department of Biology, Stanford University, Stanford, CA, United States
| | | | - Carolyn R. Bertozzi
- Department of Chemistry, Stanford University, Stanford, CA, United States,Howard Hughes Medical Institute, Stanford University, Stanford, CA, United States
| | - Neil A. Martinson
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa,Johns Hopkins University Center for TB Research, Baltimore, MD, United States
| | - Bavesh D. Kana
- Department of Science and Innovation/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, The National Health Laboratory Service, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,*Correspondence: Bavesh D. Kana,
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8
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Alffenaar JWC, de Steenwinkel JEM, Diacon AH, Simonsson USH, Srivastava S, Wicha SG. Pharmacokinetics and pharmacodynamics of anti-tuberculosis drugs: An evaluation of in vitro, in vivo methodologies and human studies. Front Pharmacol 2022; 13:1063453. [PMID: 36569287 PMCID: PMC9780293 DOI: 10.3389/fphar.2022.1063453] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
There has been an increased interest in pharmacokinetics and pharmacodynamics (PKPD) of anti-tuberculosis drugs. A better understanding of the relationship between drug exposure, antimicrobial kill and acquired drug resistance is essential not only to optimize current treatment regimens but also to design appropriately dosed regimens with new anti-tuberculosis drugs. Although the interest in PKPD has resulted in an increased number of studies, the actual bench-to-bedside translation is somewhat limited. One of the reasons could be differences in methodologies and outcome assessments that makes it difficult to compare the studies. In this paper we summarize most relevant in vitro, in vivo, in silico and human PKPD studies performed to optimize the drug dose and regimens for treatment of tuberculosis. The in vitro assessment focuses on MIC determination, static time-kill kinetics, and dynamic hollow fibre infection models to investigate acquisition of resistance and killing of Mycobacterium tuberculosis populations in various metabolic states. The in vivo assessment focuses on the various animal models, routes of infection, PK at the site of infection, PD read-outs, biomarkers and differences in treatment outcome evaluation (relapse and death). For human PKPD we focus on early bactericidal activity studies and inclusion of PK and therapeutic drug monitoring in clinical trials. Modelling and simulation approaches that are used to evaluate and link the different data types will be discussed. We also describe the concept of different studies, study design, importance of uniform reporting including microbiological and clinical outcome assessments, and modelling approaches. We aim to encourage researchers to consider methods of assessing and reporting PKPD of anti-tuberculosis drugs when designing studies. This will improve appropriate comparison between studies and accelerate the progress in the field.
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Affiliation(s)
- Jan-Willem C. Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia,School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia,*Correspondence: Jan-Willem C. Alffenaar,
| | | | | | | | - Shashikant Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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9
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Mishra S, Saito K. Clinically encountered growth phenotypes of tuberculosis-causing bacilli and their in vitro study: A review. Front Cell Infect Microbiol 2022; 12:1029111. [PMID: 36439231 PMCID: PMC9684195 DOI: 10.3389/fcimb.2022.1029111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/20/2022] [Indexed: 07/11/2024] Open
Abstract
The clinical manifestations of tuberculosis (TB) vary widely in severity, site of infection, and outcomes of treatment-leading to simultaneous efforts to individualize therapy safely and to search for shorter regimens that can be successfully used across the clinical spectrum. In these endeavors, clinicians and researchers alike employ mycobacterial culture in rich media. However, even within the same patient, individual bacilli among the population can exhibit substantial variability in their culturability. Bacilli in vitro also demonstrate substantial heterogeneity in replication rate and cultivation requirements, as well as susceptibility to killing by antimicrobials. Understanding parallels in clinical, ex vivo and in vitro growth phenotype diversity may be key to identifying those phenotypes responsible for treatment failure, relapse, and the reactivation of bacilli that progresses TB infection to disease. This review briefly summarizes the current role of mycobacterial culture in the care of patients with TB and the ex vivo evidence of variability in TB culturability. We then discuss current advances in in vitro models that study heterogenous subpopulations within a genetically identical bulk culture, with an emphasis on the effect of oxidative stress on bacillary cultivation requirements. The review highlights the complexity that heterogeneity in mycobacterial growth brings to the interpretation of culture in clinical settings and research. It also underscores the intricacies present in the interplay between growth phenotypes and antimicrobial susceptibility. Better understanding of population dynamics and growth requirements over time and space promises to aid both the attempts to individualize TB treatment and to find uniformly effective therapies.
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Affiliation(s)
- Saurabh Mishra
- Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, United States
| | - Kohta Saito
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
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10
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Heyckendorf J, Georghiou SB, Frahm N, Heinrich N, Kontsevaya I, Reimann M, Holtzman D, Imperial M, Cirillo DM, Gillespie SH, Ruhwald M. Tuberculosis Treatment Monitoring and Outcome Measures: New Interest and New Strategies. Clin Microbiol Rev 2022; 35:e0022721. [PMID: 35311552 PMCID: PMC9491169 DOI: 10.1128/cmr.00227-21] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Despite the advent of new diagnostics, drugs and regimens, tuberculosis (TB) remains a global public health threat. A significant challenge for TB control efforts has been the monitoring of TB therapy and determination of TB treatment success. Current recommendations for TB treatment monitoring rely on sputum and culture conversion, which have low sensitivity and long turnaround times, present biohazard risk, and are prone to contamination, undermining their usefulness as clinical treatment monitoring tools and for drug development. We review the pipeline of molecular technologies and assays that serve as suitable substitutes for current culture-based readouts for treatment response and outcome with the potential to change TB therapy monitoring and accelerate drug development.
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Affiliation(s)
- Jan Heyckendorf
- Department of Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | | | - Nicole Frahm
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | - Irina Kontsevaya
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Maja Reimann
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - David Holtzman
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
| | - Marjorie Imperial
- University of California San Francisco, San Francisco, California, USA, United States
| | - Daniela M. Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stephen H. Gillespie
- School of Medicine, University of St Andrewsgrid.11914.3c, St Andrews, Fife, Scotland
| | - Morten Ruhwald
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
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11
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Fernandes GFS, Thompson AM, Castagnolo D, Denny WA, Dos Santos JL. Tuberculosis Drug Discovery: Challenges and New Horizons. J Med Chem 2022; 65:7489-7531. [PMID: 35612311 DOI: 10.1021/acs.jmedchem.2c00227] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Over the past 2000 years, tuberculosis (TB) has claimed more lives than any other infectious disease. In 2020 alone, TB was responsible for 1.5 million deaths worldwide, comparable to the 1.8 million deaths caused by COVID-19. The World Health Organization has stated that new TB drugs must be developed to end this pandemic. After decades of neglect in this field, a renaissance era of TB drug discovery has arrived, in which many novel candidates have entered clinical trials. However, while hundreds of molecules are reported annually as promising anti-TB agents, very few successfully progress to clinical development. In this Perspective, we critically review those anti-TB compounds published in the last 6 years that demonstrate good in vivo efficacy against Mycobacterium tuberculosis. Additionally, we highlight the main challenges and strategies for developing new TB drugs and the current global pipeline of drug candidates in clinical studies to foment fresh research perspectives.
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Affiliation(s)
- Guilherme F S Fernandes
- Department of Chemistry, University College London, 20 Gordon Street, London WC1H 0AJ, United Kingdom
| | - Andrew M Thompson
- Auckland Cancer Society Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Daniele Castagnolo
- Department of Chemistry, University College London, 20 Gordon Street, London WC1H 0AJ, United Kingdom
| | - William A Denny
- Auckland Cancer Society Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Jean L Dos Santos
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara 14800903, Brazil
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12
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Mallick JS, Nair P, Abbew ET, Van Deun A, Decroo T. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac029. [PMID: 35356403 PMCID: PMC8963286 DOI: 10.1093/jacamr/dlac029] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Drug-resistant tuberculosis (DR-TB) is considered to be a public health threat and is difficult to cure, requiring a lengthy treatment with potent, potentially toxic drugs. The novel antimicrobial agent bedaquiline has shown promising results for patients with DR-TB, improving the rate of culture conversion and reducing TB-related mortality. However, increasing numbers of cases with acquired bedaquiline resistance (ABR) have been reported in recent years. Methods This systematic review aimed to assess the frequency of ABR and characteristics of patients acquiring it. Studies showing data on sequential bedaquiline drug-susceptibility testing in patients treated with a bedaquiline-containing regimen were included. The databases CENTRAL, PubMed and Embase were manually searched, and 866 unique records identified, eventually leading to the inclusion of 13 studies. Phenotypic ABR was assessed based on predefined MIC thresholds and genotypic ABR based on the emergence of resistance-associated variants. Results The median (IQR) frequency of phenotypic ABR was 2.2% (1.1%–4.6%) and 4.4% (1.8%–5.8%) for genotypic ABR. Among the studies reporting individual data of patients with ABR, the median number of likely effective drugs in a treatment regimen was five, in accordance with WHO recommendations. In regard to the utilization of important companion drugs with high and early bactericidal activity, linezolid was included in the regimen of most ABR patients, whereas the usage of other group A (fluoroquinolones) and former group B drugs (second-line injectable drugs) was rare. Conclusions Our findings suggest a relevant frequency of ABR, urging for a better protection against it. Therefore, treatment regimens should include drugs with high resistance-preventing capacity through high and early bactericidal activity.
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Affiliation(s)
- Jahan Saeed Mallick
- Institute of Tropical Medicine Antwerp, Department of Clinical Sciences, Kronenburgstraat 43, 2000 Antwerpen, Belgium
- Corresponding author. E-mail:
| | - Parvati Nair
- Institute of Tropical Medicine Antwerp, Department of Clinical Sciences, Kronenburgstraat 43, 2000 Antwerpen, Belgium
| | - Elizabeth Tabitha Abbew
- Institute of Tropical Medicine Antwerp, Department of Clinical Sciences, Kronenburgstraat 43, 2000 Antwerpen, Belgium
- Cape Coast Teaching Hospital, Interberton Road, Cape Coast, Ghana
| | | | - Tom Decroo
- Institute of Tropical Medicine Antwerp, Department of Clinical Sciences, Kronenburgstraat 43, 2000 Antwerpen, Belgium
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13
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Xie YL, de Jager VR, Chen RY, Dodd LE, Paripati P, Via LE, Follmann D, Wang J, Lumbard K, Lahouar S, Malherbe ST, Andrews J, Yu X, Goldfeder LC, Cai Y, Arora K, Loxton AG, Vanker N, Duvenhage M, Winter J, Song T, Walzl G, Diacon AH, Barry CE. Fourteen-day PET/CT imaging to monitor drug combination activity in treated individuals with tuberculosis. Sci Transl Med 2021; 13:eabd7618. [PMID: 33536283 PMCID: PMC11135015 DOI: 10.1126/scitranslmed.abd7618] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/14/2021] [Indexed: 12/20/2022]
Abstract
Early bactericidal activity studies monitor daily sputum bacterial counts in individuals with tuberculosis (TB) for 14 days during experimental drug treatment. The rate of change in sputum bacterial load over time provides an informative, but imperfect, estimate of drug activity and is considered a critical step in development of new TB drugs. In this clinical study, 160 participants with TB received isoniazid, pyrazinamide, or rifampicin, components of first-line chemotherapy, and moxifloxacin individually and in combination. In addition to standard bacterial enumeration in sputum, participants underwent 2-deoxy-2-[18F]fluoro-d-glucose positron emission tomography and computerized tomography ([18F]FDG-PET/CT) at the beginning and end of the 14-day drug treatment. Quantitating radiological responses to drug treatment provided comparative single and combination drug activity measures across lung lesion types that correlated more closely with established clinical outcomes when combined with sputum enumeration compared to sputum enumeration alone. Rifampicin and rifampicin-containing drug combinations were most effective in reducing both lung lesion volume measured by CT imaging and lesion-associated inflammation measured by PET imaging. Moxifloxacin was not superior to rifampicin in any measure by PET/CT imaging, consistent with its performance in recent phase 3 clinical trials. PET/CT imaging revealed synergy between isoniazid and pyrazinamide and demonstrated that the activity of pyrazinamide was limited to lung lesion, showing the highest FDG uptake during the first 2 weeks of drug treatment. [18F]FDG-PET/CT imaging may be useful for measuring the activity of single drugs and drug combinations during evaluation of potential new TB drug regimens before phase 3 trials.
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Affiliation(s)
- Yingda L Xie
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | | | - Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Lori E Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Laura E Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Dean Follmann
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Keith Lumbard
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Saher Lahouar
- Imaging Group, NET ESolutions Inc., McLean, VA 22102, USA
| | - Stephanus T Malherbe
- 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, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7600, South Africa
| | - Jenna Andrews
- Microbial Pathogenesis, Yale University, New Haven, CT 06520, USA
| | - Xiang Yu
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | - Lisa C Goldfeder
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | - Kriti Arora
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | - Andre G Loxton
- 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, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7600, South Africa
| | | | - Michael Duvenhage
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Jill Winter
- Catalysis Foundation for Health, San Ramon, CA 94583, USA
| | - Taeksun Song
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Gerhard Walzl
- 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, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7600, South Africa
| | - Andreas H Diacon
- TASK Applied Science, Cape Town 7500, South Africa
- Department of Medicine, Stellenbosch University, Cape Town 7505, South Africa
| | - Clifton E Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA.
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
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14
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Kempker RR, Mikiashvili L, Zhao Y, Benkeser D, Barbakadze K, Bablishvili N, Avaliani Z, Peloquin CA, Blumberg HM, Kipiani M. Clinical Outcomes Among Patients With Drug-resistant Tuberculosis Receiving Bedaquiline- or Delamanid-Containing Regimens. Clin Infect Dis 2020; 71:2336-2344. [PMID: 31712809 PMCID: PMC7713674 DOI: 10.1093/cid/ciz1107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/08/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Bedaquiline and delamanid are newly available drugs for treating multidrug-resistant tuberculosis (MDR-TB); however, there are limited data guiding their use and no comparison studies. METHODS We conducted a prospective, observational study among patients with MDR-TB in Georgia who were receiving a bedaquiline- or delamanid-based treatment regimen. Monthly sputum cultures, minimal inhibitory concentration testing, and adverse event monitoring were performed. Primary outcomes were culture conversion rates and clinical outcomes. Targeted maximum likelihood estimation and super learning were utilized to produce a covariate-adjusted proportion of outcomes for each regimen. RESULTS Among 156 patients with MDR-TB, 100 were enrolled and 95 were receiving a bedaquiline-based (n = 64) or delamanid-based (n = 31) regimen. Most were male (82%) and the median age was 38 years. Rates of previous treatment (56%) and cavitary disease (61%) were high. The most common companion drugs included linezolid, clofazimine, cycloserine, and a fluoroquinolone. The median numbers of effective drugs received among patients on bedaquiline-based (4; interquartile range [IQR], 4-4) and delamanid-based (4; IQR, 3.5-5) regimens were similar. Rates of acquired drug resistance were significantly higher among patients receiving delamanid versus bedaquiline (36% vs 10%, respectively; P < .01). Adjusted rates of sputum culture conversion at 2 months (67% vs 47%, respectively; P = .10) and 6 months (95% vs 74%, respectively; P < .01), as well as more favorable clinical outcomes (96% vs 72%, respectively; P < .01), were higher among patients receiving bedaquiline versus delamanid. CONCLUSIONS Among patients with MDR-TB, bedaquiline-based regimens were associated with higher rates of sputum culture conversion, more favorable outcomes, and a lower rate of acquired drug resistance versus delamanid-based regimens.
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Affiliation(s)
- R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - L Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Y Zhao
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - D Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - K Barbakadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - N Bablishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - C A Peloquin
- Department of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - H M Blumberg
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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15
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Optimal Sampling Strategies for Therapeutic Drug Monitoring of First-Line Tuberculosis Drugs in Patients with Tuberculosis. Clin Pharmacokinet 2020; 58:1445-1454. [PMID: 30997650 PMCID: PMC6856034 DOI: 10.1007/s40262-019-00763-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The 24-h area under the concentration–time curve (AUC24)/minimal inhibitory concentration ratio is the best predictive pharmacokinetic/pharmacodynamic (PK/PD) parameter of the efficacy of first-line anti-tuberculosis (TB) drugs. An optimal sampling strategy (OSS) is useful for accurately estimating AUC24; however, OSS has not been developed in the fed state or in the early phase of treatment for first-line anti-TB drugs. Methods An OSS for the prediction of AUC24 of isoniazid, rifampicin, ethambutol and pyrazinamide was developed for TB patients starting treatment. A prospective, randomized, crossover trial was performed during the first 3 days of treatment in which first-line anti-TB drugs were administered either intravenously or in fasting or fed conditions. The PK data were used to develop OSS with best subset selection multiple linear regression. The OSS was internally validated using a jackknife analysis and externally validated with other patients from different ethnicities and in a steady state of treatment. Results OSS using time points of 2, 4 and 8 h post-dose performed best. Bias was < 5% and imprecision was < 15% for all drugs except ethambutol in the fed condition. External validation showed that OSS2-4-8 cannot be used for rifampicin in steady state conditions. Conclusion OSS at 2, 4 and 8 h post-dose enabled an accurate and precise prediction of AUC24 values of first-line anti-TB drugs in this population. Trial Registration ClinicalTrials.gov (NCT02121314).
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16
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Appetecchia F, Consalvi S, Scarpecci C, Biava M, Poce G. SAR Analysis of Small Molecules Interfering with Energy-Metabolism in Mycobacterium tuberculosis. Pharmaceuticals (Basel) 2020; 13:E227. [PMID: 32878317 PMCID: PMC7557483 DOI: 10.3390/ph13090227] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/28/2020] [Accepted: 08/28/2020] [Indexed: 12/13/2022] Open
Abstract
Tuberculosis remains the world's top infectious killer: it caused a total of 1.5 million deaths and 10 million people fell ill with TB in 2018. Thanks to TB diagnosis and treatment, mortality has been falling in recent years, with an estimated 58 million saved lives between 2000 and 2018. However, the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) Mtb strains is a major concern that might reverse this progress. Therefore, the development of new drugs acting upon novel mechanisms of action is a high priority in the global health agenda. With the approval of bedaquiline, which targets mycobacterial energy production, and delamanid, which targets cell wall synthesis and energy production, the energy-metabolism in Mtb has received much attention in the last decade as a potential target to investigate and develop new antimycobacterial drugs. In this review, we describe potent anti-mycobacterial agents targeting the energy-metabolism at different steps with a special focus on structure-activity relationship (SAR) studies of the most advanced compound classes.
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Affiliation(s)
| | | | | | | | - Giovanna Poce
- Department of Chemistry and Technologies of Drug, Sapienza University of Rome, piazzale A. Moro 5, 00185 Rome, Italy; (F.A.); (S.C.); (C.S.); (M.B.)
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17
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Diacon A, Miyahara S, Dawson R, Sun X, Hogg E, Donahue K, Urbanowski M, De Jager V, Fletcher CV, Hafner R, Swindells S, Bishai W. Assessing whether isoniazid is essential during the first 14 days of tuberculosis therapy: a phase 2a, open-label, randomised controlled trial. LANCET MICROBE 2020; 1:e84-e92. [PMID: 33834177 DOI: 10.1016/s2666-5247(20)30011-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Clinical studies suggest that isoniazid contributes rapid bacterial killing during the initial two days of tuberculosis treatment but that isoniazid's activity declines significantly after day three. We conducted a 14-day phase IIa open label, randomized trial to assess the essentiality of isoniazid in standard tuberculosis therapy. Methods A total of 69 adults with newly diagnosed sputum-positive tuberculosis from the South African Western Cape region were enrolled and randomized to a four-arm parallel assignment model. Participants were followed for 14 days as inpatients at either the University of Cape Town Lung Institute or at the TASK Applied Science clinical research organization. All arms received standard daily rifampicin, ethambutol, and pyrazinamide but differed as follows: isoniazid only on days one and two (n=17), isoniazid on days one and two then moxifloxacin on days three through 14 (n=16), no isoniazid (n=18), and a control group that received isoniazid for all 14 days (standard therapy, n=18). The primary endpoint was the rate of colony forming unit (CFU) decline during the first 14 days of treatment. Results For 62 participants analyzed, the initial 14-day mean daily fall in log10 CFU (95% CI) was 0·14 (0·11, 0·18) for participants receiving isoniazid for two days only; 0·13 (0·09, 0·17) for participants receiving isoniazid for two days followed by moxifloxacin; 0·12 (0·08, 0·15) for those not receiving isoniazid; and 0·13 (0·09, 0·16) for the standard therapy group. Conclusions The 14 day EBA for the combination rifampicin, ethambutol, and pyrazinamide was not significantly changed by the addition of isoniazid for the first two days or for the first 14 days of treatment. In a post hoc analysis, significantly higher day-two EBAs were observed for all groups among participants with higher baseline sputum CFUs. Our finding that INH does not contribute to EBA suggests that INH could be replaced with another drug during standard treatment to improve efficacy and decrease rates of resistance to first-line drugs. (Funded by the NIH AIDS Clinical Trial Groups and NIH; A5307 ClinicalTrials.gov number, NCT01589497).
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Affiliation(s)
- Andreas Diacon
- Division of Physiology, Department of Medical Biochemistry, Stellenbosch University, Cape Town, South Africa.,Task Applied Science, Tuberculosis Clinical Research Centre, Bellville, Cape Town, South Africa
| | - Sachiko Miyahara
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Rodney Dawson
- Task Applied Science, Tuberculosis Clinical Research Centre, Bellville, Cape Town, South Africa.,University of Cape Town Lung Institute and Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Xin Sun
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Evelyn Hogg
- Social & Scientific Systems, Inc., Silver Spring, Maryland, USA
| | - Kathleen Donahue
- Frontier Science & Technology Research Foundation Inc., Amherst, New York, USA
| | - Michael Urbanowski
- Center for TB Research, Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Veronique De Jager
- Task Applied Science, Tuberculosis Clinical Research Centre, Bellville, Cape Town, South Africa
| | | | - Richard Hafner
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Susan Swindells
- Department of Internal Medicine, Division of Infectious Diseases, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - William Bishai
- Center for TB Research, Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
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18
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Abstract
Mycobacterium tuberculosis is a major public health concern and requires prompt treatment. Goals of treatment include curing the individual patient and protecting the community from ongoing tuberculosis transmission. To achieve durable cure, regimens must include multiple agents given concurrently and in a manner to ensure completion of therapy. This article focuses on preferred regimens of drug-susceptible tuberculosis under current guidelines by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America and World Health Organization. In addition, topics including patient centered care, poor treatment outcomes, and adverse effects are also discussed.
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Affiliation(s)
- Beth Shoshana Zha
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0111, 513 Parnassus Avenue, San Francisco, CA 94117, USA
| | - Payam Nahid
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0841 MD, 1001 Potrero Avenue, 5J6, San Francisco, CA 94110, USA.
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19
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Abstract
Guidelines on the treatment of tuberculosis (TB) have essentially remained the same for the past 35 years, but are now starting to change. Ongoing clinical trials will hopefully transform the landscape for treatment of drug sensitive TB, drug resistant TB, and latent TB infection. Multiple trials are evaluating novel agents, repurposed agents, adjunctive host directed therapies, and novel treatment strategies that will increase the probability of success of future clinical trials. Guidelines for HIV-TB co-infection treatment continue to be updated and drug resistance testing has been revolutionized in recent years with the shift from phenotypic to genotypic testing and the concomitant increased speed of results. These coming changes are long overdue and are sorely needed to address the vast disparities in global TB incidence rates. TB is currently the leading cause of death globally from a single infectious agent, but the work of many researchers and the contributions of many patients in clinical trials will reduce the substantial global morbidity and mortality of the disease.
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Affiliation(s)
- Anthony Lee
- Medical Research Scholars Program, National Institutes of Health, Bethesda, MD, USA
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Yingda Linda Xie
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Clifton E Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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20
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Modeling and Simulation of Pretomanid Pharmacodynamics in Pulmonary Tuberculosis Patients. Antimicrob Agents Chemother 2019:AAC.00732-19. [PMID: 31570404 DOI: 10.1128/aac.00732-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Pretomanid (PA-824) is a nitroimidazole in clinical testing for the treatment of tuberculosis. A population pharmacodynamic model for pretomanid was developed using a Bayesian analysis of efficacy data from two early bactericidal activity (EBA) studies, PA-824-CL-007 and PA-824-CL-010, conducted in Cape Town, South Africa. The two studies included 122 adult male and female participants with newly diagnosed pulmonary tuberculosis who received once daily oral pretomanid doses of either 50, 100, 150, 200, 600, 1,000, or 1,200 mg for 14 days. The structural model described capacity-limited growth and saturable drug-induced bacterial killing with separate rate equations for sputum solid culture colony forming unit (CFU) counts and liquid culture time to positivity (TTP) that were linked through a time constant. The posterior population geometric means and interindividual variability percent coefficients of variation were, respectively; 0.152±0.013 log10 CFU/mL sputum/day and 54%±6% for the maximum kill rate constant, 20.4±1.0 h and 20.8%±0.1% for the time constant of proportionality between the CFU and TTP rate equations, and 770±140 ng/mL and 48%±17% for the pretomanid half-maximum effect plasma concentration. Model simulations showed once daily pretomanid at 100 mg, 200 mg, and 300 mg, attained 58%, 73%, and 80%, respectively, of an expected maximum 14-day EBA of 0.136 log10CFU/mL sputum/day. These results establish a pretomanid exposure-efficacy relationship with dual outcomes for CFU counts and TTP, and with potential applications to dose optimization of pretomanid-containing regimens.
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21
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Impact of selective immune-cell depletion on growth of Mycobacterium tuberculosis (Mtb) in a whole-blood bactericidal activity (WBA) assay. PLoS One 2019; 14:e0216616. [PMID: 31100071 PMCID: PMC6524797 DOI: 10.1371/journal.pone.0216616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/24/2019] [Indexed: 01/08/2023] Open
Abstract
We investigated the contribution of host immune cells to bacterial killing in a whole-blood bactericidal activity (WBA) assay, an ex vivo model used to test efficacy of drugs against mycobacterium tuberculosis (Mtb). We performed WBA assays with immuno-magnetic depletion of specific cell types, in the presence or absence of rifampicin. Innate immune cells decreased Mtb growth in absence of drug, but appeared to diminish the cidal activity of rifampicin, possibly attributable to intracellular bacterial sequestration. Adaptive immune cells had no effect with or without drug. The WBA assay may have potential for testing adjunctive host-directed therapies acting on phagocytic cells.
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22
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Alffenaar JWC, Akkerman OW, Bothamley G. Monitoring during and after tuberculosis treatment. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10022217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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23
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Lee BY, Clemens DL, Silva A, Dillon BJ, Masleša-Galić S, Nava S, Ho CM, Horwitz MA. Ultra-rapid near universal TB drug regimen identified via parabolic response surface platform cures mice of both conventional and high susceptibility. PLoS One 2018; 13:e0207469. [PMID: 30427938 PMCID: PMC6235396 DOI: 10.1371/journal.pone.0207469] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022] Open
Abstract
As current treatment of tuberculosis is burdensomely long, provoking non-adherence and drug resistance, effective short-course treatments are needed. Using the output-driven parabolic response surface (PRS) platform, we have identified drug regimens that treat tuberculosis more rapidly in mice than the current Standard Regimen used in humans. We show that PRS Regimen III, comprising clofazimine, SQ109, bedaquiline and pyrazinamide, rapidly sterilizes the lung both in conventionally studied BALB/c mice and in C3HeB/FeJ mice, highly susceptible mice that develop massive necrotic granulomatous lung lesions akin to those in humans, achieving relapse-free cure in only 4 weeks (p<0.0001 versus Standard Regimen). In contrast, the Standard Regimen required 16 weeks to attain lung culture negative status and 20 weeks to achieve relapse-free cure. Thus, PRS Regimen III dramatically cuts by ~80% the time to relapse-free cure in mouse tuberculosis models. PRS Regimen III, with three nonstandard drugs, can potentially treat both drug-sensitive and most drug-resistant tuberculosis.
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Affiliation(s)
- Bai-Yu Lee
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, United States of America
| | - Daniel L. Clemens
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, United States of America
| | - Aleidy Silva
- Department of Mechanical and Aerospace Engineering, University of California, Los Angeles, California, United States of America
| | - Barbara Jane Dillon
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, United States of America
| | - Saša Masleša-Galić
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, United States of America
| | - Susana Nava
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, United States of America
| | - Chih-Ming Ho
- Department of Mechanical and Aerospace Engineering, University of California, Los Angeles, California, United States of America
- Department of Bioengineering, University of California, Los Angeles, California, United States of America
| | - Marcus A. Horwitz
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, United States of America
- * E-mail:
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24
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J Libardo MD, Boshoff HI, Barry CE. The present state of the tuberculosis drug development pipeline. Curr Opin Pharmacol 2018; 42:81-94. [PMID: 30144650 DOI: 10.1016/j.coph.2018.08.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
Abstract
Tuberculosis now ranks as the leading cause of death in the world due to a single infectious agent. Current standard of care treatment can achieve very high cure rates for drug-sensitive disease but requires a 6-month duration of chemotherapy. Drug-resistant disease requires significantly longer treatment durations with drugs associated with a higher risk of adverse events. Thus, there is a pressing need for a drug regimen that is safer, shorter in duration and superior to current front-line chemotherapy in terms of efficacy. The TB drug pipeline contains several candidates that address one or more of the required attributes of chemotherapeutic regimens that may redefine the standard of care of this disease. Several new drugs have been reported and novel targets have been identified allowing regimens containing new compounds to trickle into clinical studies. Furthermore, a recent paradigm-shift in understanding the pharmacokinetics of anti-tubercular drugs is revolutionizing the way we select compounds for clinical progression.
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Affiliation(s)
- M Daben J Libardo
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, United States
| | - Helena Im Boshoff
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, United States
| | - Clifton E Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, United States.
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25
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Abstract
![]()
Current tuberculosis
(TB) drug development efforts are not sufficient
to end the global TB epidemic. Recent efforts have focused on the
development of whole-cell screening assays because biochemical, target-based
inhibitor screens during the last two decades have not delivered new
TB drugs. Mycobacterium tuberculosis (Mtb), the causative
agent of TB, encounters diverse microenvironments and can be found
in a variety of metabolic states in the human host. Due to the complexity
and heterogeneity of Mtb infection, no single model can fully recapitulate
the in vivo conditions in which Mtb is found in TB patients, and there
is no single “standard” screening condition to generate
hit compounds for TB drug development. However, current screening
assays have become more sophisticated as researchers attempt to mirror
the complexity of TB disease in the laboratory. In this review, we
describe efforts using surrogates and engineered strains of Mtb to
focus screens on specific targets. We explain model culture systems
ranging from carbon starvation to hypoxia, and combinations thereof,
designed to represent the microenvironment which Mtb encounters in
the human body. We outline ongoing efforts to model Mtb infection
in the lung granuloma. We assess these different models, their ability
to generate hit compounds, and needs for further TB drug development,
to provide direction for future TB drug discovery.
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Affiliation(s)
- Tianao Yuan
- Department of Chemistry, Stony Brook University , Stony Brook, New York 11794-3400, United States
| | - Nicole S Sampson
- Department of Chemistry, Stony Brook University , Stony Brook, New York 11794-3400, United States.,Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University , Stellenbosch 7600, South Africa
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26
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Svensson RJ, Gillespie SH, Simonsson USH. Improved power for TB Phase IIa trials using a model-based pharmacokinetic-pharmacodynamic approach compared with commonly used analysis methods. J Antimicrob Chemother 2018; 72:2311-2319. [PMID: 28520930 PMCID: PMC5890728 DOI: 10.1093/jac/dkx129] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/05/2017] [Indexed: 01/20/2023] Open
Abstract
Background: The demand for new anti-TB drugs is high, but development programmes are long and costly. Consequently there is a need for new strategies capable of accelerating this process. Objectives: To explore the power to find statistically significant drug effects using a model-based pharmacokinetic–pharmacodynamic approach in comparison with the methods commonly used for analysing TB Phase IIa trials. Methods: Phase IIa studies of four hypothetical anti-TB drugs (labelled A, B, C and D), each with a different mechanism of action, were simulated using the multistate TB pharmacometric (MTP) model. cfu data were simulated over 14 days for patients taking once-daily monotherapy at four different doses per drug and a reference (10 mg/kg rifampicin). The simulated data were analysed using t-test, ANOVA, mono- and bi-exponential models and a pharmacokinetic–pharmacodynamic model approach (MTP model) to establish their respective power to find a drug effect at the 5% significance level. Results: For the pharmacokinetic–pharmacodynamic model approach, t-test, ANOVA, mono-exponential model and bi-exponential model, the sample sizes needed to achieve 90% power were: 10, 30, 75, 20 and 30 (drug A); 30, 75, 245, 75 and 105 (drug B); 70, >1250, 315, >1250 and >1250 (drug C); and 30, 110, 710, 170 and 185 (drug D), respectively. Conclusions: A model-based design and analysis using a pharmacokinetic–pharmacodynamic approach can reduce the number of patients required to determine a drug effect at least 2-fold compared with current methodologies. This could significantly accelerate early-phase TB drug development.
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Affiliation(s)
- Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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27
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Dartois V, Saito K, Warrier T, Nathan C. New Evidence for the Complexity of the Population Structure of Mycobacterium tuberculosis Increases the Diagnostic and Biologic Challenges. Am J Respir Crit Care Med 2017; 194:1448-1451. [PMID: 27976945 DOI: 10.1164/rccm.201607-1431ed] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Véronique Dartois
- 1 Public Health Research Institute Rutgers, The State University of New Jersey Newark, New Jersey and
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28
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Proaño A, Bravard MA, López JW, Lee GO, Bui D, Datta S, Comina G, Zimic M, Coronel J, Caviedes L, Cabrera JL, Salas A, Ticona E, Vu NM, Kirwan DE, Loader MCI, Friedland JS, Moore DAJ, Evans CA, Tracey BH, Gilman RH. Dynamics of Cough Frequency in Adults Undergoing Treatment for Pulmonary Tuberculosis. Clin Infect Dis 2017; 64:1174-1181. [PMID: 28329268 PMCID: PMC5399950 DOI: 10.1093/cid/cix039] [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: 08/29/2016] [Accepted: 01/13/2017] [Indexed: 01/01/2023] Open
Abstract
Background Cough is the major determinant of tuberculosis transmission. Despite this, there is a paucity of information regarding characteristics of cough frequency throughout the day and in response to tuberculosis therapy. Here we evaluate the circadian cycle of cough, cough frequency risk factors, and the impact of appropriate treatment on cough and bacillary load. Methods We prospectively evaluated human immunodeficiency virus-negative adults (n = 64) with a new diagnosis of culture-proven, drug-susceptible pulmonary tuberculosis immediately prior to treatment and repeatedly until treatment day 62. At each time point, participant cough was recorded (n = 670) and analyzed using the Cayetano Cough Monitor. Consecutive coughs at least 2 seconds apart were counted as separate cough episodes. Sputum samples (n = 426) were tested with microscopic-observation drug susceptibility broth culture, and in culture-positive samples (n = 252), the time to culture positivity was used to estimate bacillary load. Results The highest cough frequency occurred from 1 pm to 2 pm, and the lowest from 1 am to 2 am (2.4 vs 1.1 cough episodes/hour, respectively). Cough frequency was higher among participants who had higher sputum bacillary load (P < .01). Pretreatment median cough episodes/hour was 2.3 (interquartile range [IQR], 1.2-4.1), which at 14 treatment days decreased to 0.48 (IQR, 0.0-1.4) and at the end of the study decreased to 0.18 (IQR, 0.0-0.59) (both reductions P < .001). By 14 treatment days, the probability of culture conversion was 29% (95% confidence interval, 19%-41%). Conclusions Coughs were most frequent during daytime. Two weeks of appropriate treatment significantly reduced cough frequency and resulted in one-third of participants achieving culture conversion. Thus, treatment by 2 weeks considerably diminishes, but does not eliminate, the potential for airborne tuberculosis transmission.
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Affiliation(s)
- Alvaro Proaño
- Escuela Profesional de Medicina, Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Perú
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia
| | - Marjory A Bravard
- Asociación Benéfica PRISMA, Lima, Perú
- Department of General Internal Medicine, Massachusetts General Hospital, Boston, USA
- Innovation For Health And Development, Laboratory of Research and Development,Universidad Peruana Cayetano Heredia, Lima, Peru
| | - José W López
- Laboratorio de Bioinformática y Biología Molecular, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Perú
- Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - Gwenyth O Lee
- Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, Louisiana
| | - David Bui
- Division of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson
| | - Sumona Datta
- Innovation For Health And Development, Laboratory of Research and Development,Universidad Peruana Cayetano Heredia, Lima, Peru
- Infectious Diseases and Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Germán Comina
- Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, Louisiana
- Escuela Profesional de Ingeniería Física, Facultad de Ciencias, Universidad Nacional de Ingeniería
| | - Mirko Zimic
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia
- Laboratorio de Bioinformática y Biología Molecular, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Jorge Coronel
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia
| | - Luz Caviedes
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia
| | - José L Cabrera
- Servicio de Neumología, Hospital Nacional Alcides Carrión,Bellavista , Peru
| | - Antonio Salas
- Servicio de Neumología, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Eduardo Ticona
- Facultad de Medicina, Univ Nacional Mayor de San Marcosersidad, Lima, Peru
- Servicio de Enfermedades Infecciosas y Tropicales, Hospital Nacional Dos de Mayo, Lima, Perú
| | - Nancy M Vu
- Department of Internal Medicine, Cleveland Clinic, Ohio, USA
| | - Daniela E Kirwan
- Infectious Diseases and Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Maria-Cristina I Loader
- Infectious Diseases and Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Jon S Friedland
- Infectious Diseases and Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - David A J Moore
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia
- Asociación Benéfica PRISMA, Lima, Perú
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Carlton A Evans
- Asociación Benéfica PRISMA, Lima, Perú
- Innovation For Health And Development, Laboratory of Research and Development,Universidad Peruana Cayetano Heredia, Lima, Peru
- Infectious Diseases and Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Brian H Tracey
- Department of Electrical and Computer Engineering, Tufts University, Medford, Massachusetts, USA
| | - Robert H Gilman
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia
- Asociación Benéfica PRISMA, Lima, Perú
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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29
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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: 655] [Impact Index Per Article: 81.9] [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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30
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Pouplin T, Bang ND, Toi PV, Phuong PN, Dung NH, Duong TN, Caws M, Thwaites GE, Tarning J, Day JN. Naïve-pooled pharmacokinetic analysis of pyrazinamide, isoniazid and rifampicin in plasma and cerebrospinal fluid of Vietnamese children with tuberculous meningitis. BMC Infect Dis 2016; 16:144. [PMID: 27039088 PMCID: PMC4818938 DOI: 10.1186/s12879-016-1470-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 03/14/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Among the various forms of TB, tuberculous meningitis (TBM) is the most severe, with about 30% mortality and 50% of survivors left with neurological sequelae. Children suffer more frequently from TBM than adults and outcomes are often poor due to difficulties in making the diagnosis and uncertainty regarding the best anti-tuberculosis drug regimen. The aim of this prospective study was to describe the pharmacokinetics of pyrazinamide, isoniazid and rifampicin in plasma and cerebrospinal fluid of children with tuberculous meningitis treated with the standard TBM regimen. METHODS We performed a prospective observational study of 100 consecutively treated children (≤ 15 years of age) with tuberculous meningitis in Ho Chi Minh City, Vietnam. Children were treated according to the 2006 WHO recommended pediatric treatment regimen consisting of isoniazid (5 mg/kg), rifampicin (10 mg/kg) and ethambutol (15 mg/kg) for 8 months, with the addition of pyrazinamide (25 mg/kg) for the first 3 months and streptomycin (15 mg/kg) for the first 2 months. Pyrazinamide, isoniazid and rifampicin concentrations were measured in plasma at day 14 and in cerebrospinal fluid (CSF) at 1 month by HPLC-UV. A naïve-pooled non-compartmental data analysis was used to describe the pharmacokinetic properties of drugs in the two-age groups of children ≤ 4 years or > 4 years of age. RESULTS Younger children, when compared to older children, presented a higher body weight-normalized clearance and volume of distribution, and lower median total plasma exposures for the three studied drugs with -14%, -22% and -16% for Pyrazinamide, Isoniazid and Rifampicin, respectively. In CSF, individual concentrations of isoniazid and pyrazinamide were comparable to that in plasma in both age groups; but rifampicin concentrations were lower than the minimum inhibitory concentration of susceptible bacteria in all but two children. CONCLUSIONS There is an age-dependent variation in the plasma and cerebrospinal fluid pharmacokinetics of rifampicin, isoniazid and pyrazinamide. The safety and efficacy of higher doses of rifampicin should be investigated for the treatment of childhood tuberculous meningitis.
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Affiliation(s)
- Thomas Pouplin
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nguyen Duc Bang
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | - Pham Van Toi
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
| | - Pham Nguyen Phuong
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
| | | | | | - Maxine Caws
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jeremy N Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
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31
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Rockwood N, du Bruyn E, Morris T, Wilkinson RJ. Assessment of treatment response in tuberculosis. Expert Rev Respir Med 2016; 10:643-54. [PMID: 27030924 DOI: 10.1586/17476348.2016.1166960] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Antibiotic treatment of tuberculosis has a duration of several months. There is significant variability of the host immune response and the pharmacokinetic-pharmacodynamic properties of Mycobacterium tuberculosis sub-populations at the site of disease. A limitation of sputum-based measures of treatment response may be sub-optimal detection and monitoring of Mycobacterium tuberculosis sub-populations. Potential biomarkers and surrogate endpoints should be benchmarked against hard clinical outcomes (failure/relapse/death) and may need tailoring to specific patient populations. Here, we assess the evidence supporting currently utilized and future potential host and pathogen-based models and biomarkers for monitoring treatment response in active and latent tuberculosis. Biomarkers for monitoring treatment response in extrapulmonary, pediatric and drug resistant tuberculosis are research priorities.
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Affiliation(s)
- Neesha Rockwood
- a Department of Medicine , Imperial College London , London , UK.,b Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine , University of Cape Town , Observatory , South Africa
| | - Elsa du Bruyn
- b Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine , University of Cape Town , Observatory , South Africa
| | - Thomas Morris
- a Department of Medicine , Imperial College London , London , UK
| | - Robert J Wilkinson
- a Department of Medicine , Imperial College London , London , UK.,b Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine , University of Cape Town , Observatory , South Africa.,c The Francis Crick Institute Mill Hill Laboratory , London , UK
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Zuur MA, Bolhuis MS, Anthony R, den Hertog A, van der Laan T, Wilffert B, de Lange W, van Soolingen D, Alffenaar JWC. Current status and opportunities for therapeutic drug monitoring in the treatment of tuberculosis. Expert Opin Drug Metab Toxicol 2016; 12:509-21. [DOI: 10.1517/17425255.2016.1162785] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Marlanka A. Zuur
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathieu S. Bolhuis
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard Anthony
- Royal Tropical Institute (KIT), KIT Biomedical Research, Amsterdam, The Netherlands
| | - Alice den Hertog
- Royal Tropical Institute (KIT), KIT Biomedical Research, Amsterdam, The Netherlands
| | - Tridia van der Laan
- National Tuberculosis Reference Laboratory, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Bob Wilffert
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pharmacy, section Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands
| | - Wiel de Lange
- University of Groningen, University Medical Center Groningen, Tuberculosis Centre Beatrixoord, Haren, The Netherlands
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dick van Soolingen
- National Tuberculosis Reference Laboratory, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Departments of Pulmonary Diseases and Medical Microbiology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jan-Willem C. Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Kayigire XA, Friedrich SO, van der Merwe L, Donald PR, Diacon AH. Simultaneous staining of sputum smears for acid-fast and lipid-containing Myobacterium tuberculosis can enhance the clinical evaluation of antituberculosis treatments. Tuberculosis (Edinb) 2015; 95:770-779. [DOI: 10.1016/j.tube.2015.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/24/2015] [Accepted: 08/02/2015] [Indexed: 10/23/2022]
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Esposito S, Bianchini S, Blasi F. Bedaquiline and delamanid in tuberculosis. Expert Opin Pharmacother 2015; 16:2319-30. [DOI: 10.1517/14656566.2015.1080240] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sulfamethoxazole susceptibility of Mycobacterium tuberculosis isolates from HIV-infected Ugandan adults with tuberculosis taking trimethoprim-sulfamethoxazole prophylaxis. Antimicrob Agents Chemother 2015; 59:5844-6. [PMID: 26169400 DOI: 10.1128/aac.01101-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/03/2015] [Indexed: 11/20/2022] Open
Abstract
Additional drugs are needed for the treatment of multidrug-resistant tuberculosis (TB). Sulfamethoxazole has been shown to have in vitro activity against Mycobacterium tuberculosis; however, there is concern about resistance given the widespread use of trimethoprim-sulfamethoxazole prophylaxis among HIV-infected patients in sub-Saharan Africa. Thirty-eight of 40 Mycobacterium tuberculosis isolates (95%) from pretreatment sputum samples from Ugandan adults with pulmonary TB, including HIV-infected patients taking trimethoprim-sulfamethoxazole prophylaxis, were susceptible with MICs of ≤38.4 μg/ml.
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Thee S, Garcia-Prats A, Donald P, Hesseling A, Schaaf H. Fluoroquinolones for the treatment of tuberculosis in children. Tuberculosis (Edinb) 2015; 95:229-45. [DOI: 10.1016/j.tube.2015.02.037] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 02/06/2015] [Indexed: 01/08/2023]
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Olaru ID, von Groote-Bidlingmaier F, Heyckendorf J, Yew WW, Lange C, Chang KC. Novel drugs against tuberculosis: a clinician's perspective. Eur Respir J 2014; 45:1119-31. [PMID: 25431273 DOI: 10.1183/09031936.00162314] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The United Nations Millennium Development Goal of reversing the global spread of tuberculosis by 2015 has been offset by the rampant re-emergence of drug-resistant tuberculosis, in particular fluoroquinolone-resistant multidrug-resistant and extensively drug-resistant tuberculosis. After decades of quiescence in the development of antituberculosis medications, bedaquiline and delamanid have been conditionally approved for the treatment of drug-resistant tuberculosis, while several other novel compounds (AZD5847, PA-824, SQ109 and sutezolid) have been evaluated in phase II clinical trials. Before novel drugs can find their place in the battle against drug-resistant tuberculosis, linezolid has been compassionately used with success in the treatment of fluoroquinolone-resistant multidrug-resistant tuberculosis. This review largely discusses six novel drugs that have been evaluated in phase II and III clinical trials, with focus on the clinical evidence for efficacy and safety, potential drug interactions, and prospect for using multiple novel drugs in new regimens.
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Affiliation(s)
- Ioana Diana Olaru
- Division of Clinical Infectious Diseases, Research Center Borstel, German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | | | - Jan Heyckendorf
- Division of Clinical Infectious Diseases, Research Center Borstel, German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Wing Wai Yew
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany Dept of Internal Medicine, University of Namibia School of Medicine, Windhoek, Namibia Dept of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Dept of Health, Hong Kong, China
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Kwon YS, Jeong BH, Koh WJ. Delamanid when other anti-tuberculosis-treatment regimens failed due to resistance or tolerability. Expert Opin Pharmacother 2014; 16:253-61. [PMID: 25327169 DOI: 10.1517/14656566.2015.973853] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The limited availability of effective drugs causes difficulties in the management of multidrug-resistant tuberculosis (MDR-TB) and novel therapeutic agents are needed. Delamanid , a new nitro-hydro-imidazooxazole derivative, inhibits mycolic acid synthesis. This review covers the efficacy and safety of delamanid for MDR-TB. AREA COVERED This paper reviews the pharmacological profile of delamanid and the results of clinical trials evaluating its efficacy for treating MDR-TB in combination with other anti-TB drugs. The drug's safety and tolerability profiles are also considered. EXPERT OPINION Delamanid showed potent activity against drug-susceptible and -resistant Mycobacterium tuberculosis in both in vitro and in vivo studies. In clinical trials, the drug showed significant early bactericidal activity in pulmonary TB patients, and increased culture conversion after 2 months of treatment in combination with an optimized background regimen in MDR-TB patients. In addition, decreased mortality was observed in MDR-TB patients who received > 6 months of delamanid treatment. The drug was generally tolerable, but QT prolongation should be monitored carefully using electrocardiograms and potassium levels. Therefore, delamanid could be used as part of an appropriate combination regimen for pulmonary MDR-TB in adult patients when an effective treatment regimen cannot otherwise be composed for reasons of resistance or tolerability.
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Affiliation(s)
- Yong-Soo Kwon
- Chonnam National University Hospital, Department of Internal Medicine , Gwangju , South Korea
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