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Saluzzo F, Masood F, Batignani V, Di Marco F, Majeed U, Ghazal A, Cirillo DM, Tahseen S. TB drug susceptibility testing in high fluoroquinolone resistance settings. IJTLD OPEN 2024; 1:230-235. [PMID: 39022777 PMCID: PMC11249602 DOI: 10.5588/ijtldopen.24.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/14/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The insurgence of resistance to key drugs of the BPaLM (bedaquiline + pretomanid + moxifloxacin) regimen is a major concern. In settings with widespread resistance to fluoroquinolones (FQs), like Pakistan, new technologies, such as Xpert® MTB/XDR, may ensure drug resistance upfront screening. This study aims to assess MTB/XDR's performance in detecting FQs and isoniazid resistance, proposing a renewed diagnostic algorithm for drug-resistant TB (DR-TB). METHODS This cross-sectional prospective study, approved by the local ethical committee, collected samples from people newly and previously diagnosed with TB over 6 months. Xpert® MTB/RIF Ultra, MTB/XDR, Genotype® MTBDRplus, Genotype® MTBDRsl, culture, and phenotypic drug susceptibility testing (pDST) for relevant drugs (including bedaquiline and levofloxacin) were performed. Next-generation sequencing (NGS) resolved discordances between MTB/XDR and pDST results. RESULTS The analysis showed that MTB/XDR has 91.5% and 88.2% sensitivity and 99.5% and 97.7% specificity in detecting respectively isoniazid (INH) and resistance to FQs, demonstrating that MTB/XDR meets the WHO targets for INH resistance detection at the peripheral level. NGS effectively resolved discordances between MTB/XDR and pDST results. CONCLUSIONS The obtained results allowed designing the proposed diagnostic algorithm for rapid identification of DR-TB, ensuring rapid and equitable access to drug susceptibility testing for TB, ultimately improving TB care and control.
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Affiliation(s)
- F Saluzzo
- Vita Salute San Raffaele University, Milan
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Masood
- National TB Control Programme, Islamabad
- National TB Reference Laboratory, Islamabad, Pakistan
| | - V Batignani
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Di Marco
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - U Majeed
- National TB Control Programme, Islamabad
- National TB Reference Laboratory, Islamabad, Pakistan
| | - A Ghazal
- National TB Control Programme, Islamabad
- National TB Reference Laboratory, Islamabad, Pakistan
| | - D M Cirillo
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Tahseen
- National TB Control Programme, Islamabad
- National TB Reference Laboratory, Islamabad, Pakistan
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Tahseen S, Khanzada FM, Rizvi AH, Qadir M, Ghazal A, Baloch AQ, Mustafa T. Isoniazid resistance profile and associated levofloxacin and pyrazinamide resistance in rifampicin resistant and sensitive isolates/from pulmonary and extrapulmonary tuberculosis patients in Pakistan: A laboratory based surveillance study 2015-19. PLoS One 2020; 15:e0239328. [PMID: 32966321 PMCID: PMC7511002 DOI: 10.1371/journal.pone.0239328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/04/2020] [Indexed: 11/29/2022] Open
Abstract
Background Pakistan is among top five high burden countries for tuberculosis and drug resistant TB. Among rifampicin sensitive new pulmonary TB (PTB), prevalence of isoniazid resistance is 8.3% (95%CI: 7.0–10.7) and resistance to fluoroquinolone is higher (11·1%, 95%CI: 7·8–14·3) than isoniazid resistance. Method Five year retrospective data (2015–2019) of drug susceptibility testing (DST) for Mycobacterium tuberculosis isolates, performed using recommended phenotypic (pDST) and/or genotypic (gDST) methods was analyzed stratified by rifampicin results for isoniazid resistance profiles and associated levofloxacin and pyrazinamide resistance. Findings DST data was analyzed from 11045 TB patients. Isolates were tested using pDST (87%), gDST (92%) and both methods (79.5%). For both rifampicin and isoniazid, a significant difference (P < .001) was noted between resistance detected by pDST and gDST. Among isolates, tested by both methods (8787), 49% were resistant to rifampicin and 51.7% to isoniazid with discordance in resistant results of 15.8% for each, with 13.2% (570) of rifampicin resistance reported sensitive by pDST and 14.2% (660) of isoniazid resistance missed by gDST. Estimated isoniazid resistance among rifampicin sensitive new PTB, extrapulmonary TB and previously treated PTB was 9.8% (95%CI: 8.7–11.1), 6.8% (95%CI: 5.4–8.5) and 14.6% (95%CI: 11.8–17.9) respectively. Significant differences were reported between the genotypic profile of isoniazid resistance associated with rifampicin-resistant and sensitive isolates including detectable mutations (87% vs 71.6%), frequency of inhA (7.6% and 30.2%) and katG mutations (76.1% vs 41.2%) respectively. Among rifampicin resistant and sensitive isolates, a significantly higher level of resistance to levofloxacin and pyrazinamide was seen associated with isoniazid resistance. Conclusion There are risks and many challenges in implementing WHO recommended treatment for isoniazid resistant tuberculosis. The laboratory based surveillance can complement random surveys in country specific planning for TB diagnostics and appropriate treatment regimens.
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Affiliation(s)
- Sabira Tahseen
- National TB Reference Laboratory, National TB Control Program, Islamabad, Pakistan
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- * E-mail:
| | | | | | - Mahmood Qadir
- National TB Reference Laboratory, National TB Control Program, Islamabad, Pakistan
| | - Aisha Ghazal
- National TB Reference Laboratory, National TB Control Program, Islamabad, Pakistan
| | - Aurangzaib Quadir Baloch
- National TB Control Program, Ministry of National Health Services Regulation and Coordination, Islamabad, Pakistan
| | - Tehmina Mustafa
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
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Sayadi M, Zare H, Jamedar SA, Hashemy SI, Meshkat Z, Soleimanpour S, Hoffner S, Ghazvini K. Genotypic and phenotypic characterization of Mycobacterium tuberculosis resistance against fluoroquinolones in the northeast of Iran. BMC Infect Dis 2020; 20:390. [PMID: 32487030 PMCID: PMC7268510 DOI: 10.1186/s12879-020-05112-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Fluoroquinolones are broad-spectrum antibiotics that are recommended, and increasingly important, for the treatment of multidrug-resistant tuberculosis (MDR-TB). Resistance to fluoroquinolones is caused by mutations in the Quinolone Resistance Determining Region (QRDR) of gyrA and gyrB genes of Mycobacterium tuberculosis. In this study, we characterized the phenotypic and genotypic resistance to fluoroquinolones for the first time in northeast Iran. METHODS A total of 123 Mycobacterium tuberculosis isolates, including 111 clinical and 12 collected multidrug-resistant isolates were studied. Also, 19 WHO quality control strains were included in the study. The phenotypic susceptibility was determined by the proportion method on Löwenstein-Jensen medium. The molecular cause of resistance to the fluoroquinolone drugs ofloxacin and levofloxacin was investigated by sequencing of the QRDR region of the gyrA and gyrB genes. RESULTS Among 123 isolates, six (4.8%) were fluoroquinolone-resistant according to phenotypic methods, and genotypically three of them had a mutation at codon 94 of the gyrA gene (Asp→ Gly) which was earlier reported to cause resistance. All three remaining phenotypically resistant isolates had a nucleotide change in codon 95. No mutations were found in the gyrB gene. Five of the 19 WHO quality control strains, were phenotypically fluoroquinolone-resistant, four of them were genotypically resistant with mutations at codon 90, 91 of the gyrA gene and one resistant strain had no detected mutation. CONCLUSIONS Mutation at codon 94 of the gyrA gene, was the main cause of fluoroquinolone resistance among M. tuberculosis isolates in our region. In 3/6 fluoroquinolone-resistant isolates, no mutations were found in either gyrA or gyrB. Therefore, it can be concluded that various other factors may lead to fluoroquinolone resistance, such as active efflux pumps, decreased cell wall permeability, and drug inactivation.
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Affiliation(s)
- Mahdieh Sayadi
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hosna Zare
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Amel Jamedar
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Isaac Hashemy
- Department of Clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Meshkat
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saman Soleimanpour
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sven Hoffner
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Kiarash Ghazvini
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Liu Q, Lu P, Martinez L, Yang H, Lu W, Ding X, Zhu L. Factors affecting time to sputum culture conversion and treatment outcome of patients with multidrug-resistant tuberculosis in China. BMC Infect Dis 2018; 18:114. [PMID: 29510666 PMCID: PMC5840772 DOI: 10.1186/s12879-018-3021-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 02/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few prospective cohort studies, none in China, have investigated the relationship between treatment outcomes of multidrug-resistant tuberculosis (MDR-TB) patients and sputum culture conversion. Factors affecting the time of the culture conversion throughout the whole course of the treatment have rarely been investigated. METHODS This study was performed in four cities in Jiangsu province, China. MDR-TB patients were consecutively enrolled between December 2011 and March 2014. Rates of sputum culture conversion were calculated and Cox proportional-hazards model was performed. Factors contributing to sputum culture conversion were investigated. RESULTS In all, 139 MDR-TB patients with treatment outcomes were enrolled. Median time to culture conversion among those who converted was 91.5 days (interquartile range, 34.0-110.8 days). After multivariable analysis, smoking (HR = 0.44; 95% CI: 0.23-0.83), drinking (HR = 0.41; 95% CI: 0.21-0.81), ofloxacin resistance (HR = 0.43; 95% CI: 0.24-0.76) and sputum smear grade > 1 (HR = 0.51; 95% CI: 0.31-0.83) were less likely to have culture conversion. CONCLUSIONS MDR-TB patients who smoke, drink, have ofloxacin resistance, or a high smear grade are less likely to respond to treatment and should be meticulously followed up.
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Affiliation(s)
- Qiao Liu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, People's Republic of China
| | - Peng Lu
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, People's Republic of China
| | - Leonardo Martinez
- Department of Epidemiology and Biostatistics, University of Georgia School of Public Health, Athens, Georgia
| | - Haitao Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, People's Republic of China.,Institute of Parasitic Disease of Jiangsu Province, Wuxi, Jiangsu Province, People's Republic of China
| | - Wei Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, People's Republic of China
| | - Xiaoyan Ding
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, People's Republic of China
| | - Limei Zhu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, People's Republic of China.
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Predictors of poor treatment outcomes in multidrug-resistant tuberculosis patients: a retrospective cohort study. Clin Microbiol Infect 2017; 24:612-617. [PMID: 28970158 DOI: 10.1016/j.cmi.2017.09.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 09/05/2017] [Accepted: 09/11/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We aimed to determine the characteristics, treatment outcomes and risk factors for poor treatment outcomes among multidrug-resistant (MDR) tuberculosis (TB) patients in Khyber Pakhtunkhwa province, Pakistan. METHODS A retrospective cohort study including all patients with MDR-TB who sought care at the MDR-TB unit in Peshawar was conducted between January 2012 and April 2014. Patients were followed until an outcome of TB treatment was recorded as successful (cured or completed) or unsuccessful. Binary logistic regression was used to identify predictors of poor outcome, i.e. unsuccessful treatment outcomes. RESULTS Overall, 535 patients were included. The proportion of female subjects was relatively higher (n = 300, 56.1%) than male subjects. The mean (standard deviation) age of patients was 30.37 (14.09) years. Of 535 patients for whom treatment outcomes were available, 402 (75.1%) were cured, 4 (0.7%) completed therapy, 34 (6.4%) had disease that failed to respond to therapy, 93 (17.4%) died and two (0.4%) defaulted; in total, 129 (24.1%) had an unsuccessful outcome. We found three significant predictors of unsuccessful treatment during multivariate logistic regression: being married (odds ratio (OR) = 2.17, 95% confidence interval (CI) 1.01, 4.66), resistance to second-line drugs (OR = 2.61, 95% CI 1.61, 4.21) and presence of extensively drug-resistant TB (OR = 7.82, 95% CI 2.90, 21.07). CONCLUSIONS Approximately 75% of the treatment success rate set by the Global Plan to Stop TB was achieved. Resistance to second-line drugs and presence of extensively drug-resistant TB are the main risk factors for poor treatment outcomes.
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Zaidi SMA, Haseeb A, Habib SS, Malik A, Khowaja S, SaifUllah N, Rizvi N. Emergence of fluoroquinolone resistance among drug resistant tuberculosis patients at a tertiary care facility in Karachi, Pakistan. BMC Res Notes 2017; 10:313. [PMID: 28743312 PMCID: PMC5526320 DOI: 10.1186/s13104-017-2633-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 07/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pakistan is classified as one of the high multi-drug resistant tuberculosis (MDR-TB) burden countries. A poorly regulated private sector, over-prescription of antibiotics and self-medication has led to augmented rates of drug-resistance in the country. Pakistan's first national anti-tuberculosis drug resistance survey identified high prevalence of fluoroquinolone resistance among MDR-TB patients. Further institutional evidence of fluoroquinolone drug-resistance can support re-evaluation of treatment regimens as well as invigorate efforts to control antibiotic resistance in the country. FINDINGS In this study, data for drug-susceptibility testing (DST) was retrospectively analyzed for a total of 133 patients receiving MDR-TB treatment at the Chest Department of Jinnah Postgraduate Medical Center, Karachi, Pakistan. Frequency analyses for resistance patterns was carried out and association of fluoroquinolone (ofloxacin) resistance with demographics and past TB treatment category were assessed. Within first-line drugs, resistance to isoniazid was detected in 97.7% of cases, followed by rifampicin (96.9%), pyrazinamide (86.4%), ethambutol (69.2%) and streptomycin (64.6%). Within second-line drugs, ofloxacin resistance was detected in 34.6% of cases. Resistance to ethionamide and amikacin was 2.3% and 1.6%, respectively. Combined resistance of oflaxacin and isoniazid was detected in 33.9% of cases. Age, gender and past TB treatment category were not significantly associated with resistance to ofloxacin. CONCLUSION Fluoroquinolone resistance was observed in an alarmingly high proportion of MDR-TB cases. Our results suggest caution in their use for empirical management of MDR-TB cases and recommended treatment regimens for MDR-TB may require re-evaluation. Greater engagement of private providers and stringent pharmacy regulations are urgently required.
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Affiliation(s)
- Syed Mohammad Asad Zaidi
- Interactive Research & Development, Suite 508, Ibrahim Trade Tower, Main Shahrah-e-Faisal, Karachi, Pakistan
| | - Abdul Haseeb
- Department of Chest Medicine, Jinnah Post Graduate Medical Centre, Rafiqi H J Rd, Karachi, Pakistan
| | - Shifa Salman Habib
- Interactive Research & Development, Suite 508, Ibrahim Trade Tower, Main Shahrah-e-Faisal, Karachi, Pakistan
| | - Amyn Malik
- Interactive Research & Development, Suite 508, Ibrahim Trade Tower, Main Shahrah-e-Faisal, Karachi, Pakistan
| | - Saira Khowaja
- Interactive Research & Development, Suite 508, Ibrahim Trade Tower, Main Shahrah-e-Faisal, Karachi, Pakistan
| | - Nausheen SaifUllah
- Department of Chest Medicine, Jinnah Post Graduate Medical Centre, Rafiqi H J Rd, Karachi, Pakistan
| | - Nadeem Rizvi
- Department of Chest Medicine, Jinnah Post Graduate Medical Centre, Rafiqi H J Rd, Karachi, Pakistan
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Shrivastava N, Set R, Bankar S, Shastri J. Detection of ofloxacin resistance by nitrate reductase assay in Mycobacterium tuberculosis isolates from extrapulmonary tuberculosis. Indian J Med Microbiol 2017; 35:69-73. [PMID: 28303821 DOI: 10.4103/ijmm.ijmm_16_266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
CONTEXT Increased use of fluoroquinolones to treat community-acquired infections has led to the decreased susceptibility to Mycobacterium tuberculosis. There is a paucity of data on ofloxacin (OFX) resistance detection by nitrate reductase assay (NRA). Hence, the present study was carried out to find the efficacy of NRA for detection of OFX resistance in M. tuberculosis isolated from extrapulmonary tuberculosis (EPTB) cases. AIMS (1) To compare sensitivity, specificity and median time required to obtain results by NRA with economic variant proportion method (PM) for detection of OFX resistance.(2) To determine the extent of OFX resistance in clinical isolates of M. tuberculosis. SETTINGS AND DESIGN Seventy-three M. tuberculosis isolates from cases of EPTB were subjected to economic variant of PM for isoniazid, rifampicin and OFX. NRA was done for detection of OFX resistance. SUBJECTS AND METHODS Seventy-three isolates from clinical samples of suspected EPTB received in the Department of Microbiology were included in the study. Drug susceptibility test was performed on Lowenstein-Jensen medium with and without drugs. STATISTICAL ANALYSIS USED Of turnaround time was done by Mann-Whitney test on SPSS (version 19, released in 2010, IBM Corp, Armonk NY),P < 0.05. RESULTS OFX resistance was seen in nine isolates. The sensitivity and specificity of OFX resistance by NRA was 100% and 96.87%, respectively. Median time required to obtain results by NRA was 10 days as compared to 28 days by PM. CONCLUSIONS NRA is a specific and sensitive method for detection of OFX resistance in resource-restricted settings.
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Affiliation(s)
- Neeta Shrivastava
- Department of Microbiology, TNMC and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Reena Set
- Department of Microbiology, TNMC and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Sheetal Bankar
- Department of Microbiology, TNMC and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Jayanthi Shastri
- Department of Microbiology, TNMC and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
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Shakoor S, Tahseen S, Jabeen K, Fatima R, Malik F, Rizvi A, Hasan R. Fluoroquinolone consumption and -resistance trends in Mycobacterium tuberculosis and other respiratory pathogens: Ecological antibiotic pressure and consequences in Pakistan, 2009–2015. Int J Mycobacteriol 2016; 5:412-416. [DOI: 10.1016/j.ijmyco.2016.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022] Open
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Sequence Analysis of Fluoroquinolone Resistance-Associated Genes gyrA and gyrB in Clinical Mycobacterium tuberculosis Isolates from Patients Suspected of Having Multidrug-Resistant Tuberculosis in New Delhi, India. J Clin Microbiol 2016; 54:2298-305. [PMID: 27335153 DOI: 10.1128/jcm.00670-16] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/17/2016] [Indexed: 11/20/2022] Open
Abstract
Fluoroquinolones (FQs) are broad-spectrum antibiotics recommended for the treatment of multidrug-resistant tuberculosis (MDR-TB) patients. FQ resistance, caused by mutations in the gyrA and gyrB genes of Mycobacterium tuberculosis, is increasingly reported worldwide; however, information on mutations occurring in strains from the Indian subcontinent is scarce. Hence, in this study, we aimed to characterize mutations in the gyrA and gyrB genes of acid-fast bacillus (AFB) smear-positive sediments or of M. tuberculosis isolates from AFB smear-negative samples from patients in India suspected of having MDR-TB. A total of 152 samples from patients suspected of having MDR-TB were included in the study. One hundred forty-six strains detected in these samples were characterized by sequencing of the gyrA and gyrB genes. The extracted DNA was subjected to successive amplifications using a nested PCR protocol, followed by sequencing. A total of 27 mutations were observed in the gyrA genes of 25 strains, while no mutations were observed in the gyrB genes. The most common mutations occurred at amino acid position 94 (13/27 [48.1%]); of these, the D94G mutation was the most prevalent. The gyrA mutations were significantly associated with patients with rifampin (RIF)-resistant TB. Heterozygosity was seen in 4/27 (14.8%) mutations, suggesting the occurrence of mixed populations with different antimicrobial susceptibilities. A high rate of FQ-resistant mutations (17.1%) was obtained among the isolates of TB patients suspected of having MDR-TB. These observations emphasize the need for accurate and rapid molecular tests for the detection of FQ-resistant mutations at the time of MDR-TB diagnosis.
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Jabeen K, Shakoor S, Hasan R. Fluoroquinolone-resistant tuberculosis: implications in settings with weak healthcare systems. Int J Infect Dis 2016; 32:118-23. [PMID: 25809767 DOI: 10.1016/j.ijid.2015.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 01/26/2023] Open
Abstract
Fluoroquinolones (FQ) play an essential role in the treatment and control of multidrug-resistant tuberculosis (MDR-TB). They are also being evaluated as part of newer regimens under development for drug-sensitive TB. As newer FQ-based regimens are explored, knowledge of FQ resistance data from high TB burden countries becomes essential. We examine available FQ resistance data from high TB burden countries and demonstrate the need for comprehensive surveys to evaluate FQ resistance in these countries. The factors driving FQ resistance in such conditions and the cost of such resistance to weak healthcare systems are discussed. The need for a comprehensive policy for addressing the issue of FQ resistance is highlighted.
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Affiliation(s)
- Kauser Jabeen
- Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan
| | - Sadia Shakoor
- Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan
| | - Rumina Hasan
- Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan.
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Ahmad N, Javaid A, Sulaiman SAS, Ming LC, Ahmad I, Khan AH. Resistance patterns, prevalence, and predictors of fluoroquinolones resistance in multidrug resistant tuberculosis patients. Braz J Infect Dis 2016; 20:41-7. [PMID: 26626164 PMCID: PMC9425347 DOI: 10.1016/j.bjid.2015.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/30/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Fluoroquinolones are the backbone of multidrug resistant tuberculosis treatment regimens. Despite the high burden of multidrug resistant tuberculosis in the country, little is known about drug resistance patterns, prevalence, and predictors of fluoroquinolones resistance among multidrug resistant tuberculosis patients from Pakistan. OBJECTIVE To evaluate drug resistance patterns, prevalence, and predictors of fluoroquinolones resistance in multidrug resistant tuberculosis patients. METHODS This was a cross-sectional study conducted at a programmatic management unit of drug resistant tuberculosis, Lady Reading Hospital Peshawar, Pakistan. Two hundred and forty-three newly diagnosed multidrug resistant tuberculosis patients consecutively enrolled for treatment at study site from January 1, 2012 to July 28, 2013 were included in the study. A standardized data collection form was used to collect patients' socio-demographic, microbiological, and clinical data. SPSS 16 was used for data analysis. RESULTS High degree of drug resistance (median 5 drugs, range 2-8) was observed. High proportion of patients was resistant to all five first-line anti-tuberculosis drugs (62.6%), and more than half were resistant to second line drugs (55.1%). The majority of the patients were ofloxacin resistant (52.7%). Upon multivariate analysis previous tuberculosis treatment at private (OR=1.953, p=0.034) and public private mix (OR=2.824, p=0.046) sectors were predictors of ofloxacin resistance. CONCLUSION The high degree of drug resistance observed, particularly to fluoroquinolones, is alarming. We recommend the adoption of more restrictive policies to control non-prescription sale of fluoroquinolones, its rational use by physicians, and training doctors in both private and public-private mix sectors to prevent further increase in fluoroquinolones resistant Mycobacterium tuberculosis strains.
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Affiliation(s)
- Nafees Ahmad
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
| | - Arshad Javaid
- Department of Pulmonology, Postgraduate Medical Institute, Peshawar, Pakistan
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Long Chiau Ming
- Unit for Medication Outcomes Research and Education, School of Medicine, Division of Pharmacy, University of Tasmania, Australia
| | - Izaz Ahmad
- Department of Microbiology, Quaid-i-Azam University, Islamabad, Pakistan
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Ahmad N, Khan AH, Syed Sulaiman SA, Javaid A. Fluoroquinolones resistance in multidrug-resistant tuberculosis in Pakistan and suitability of guidelines recommended standardized regimen. Int J Mycobacteriol 2015; 4:258-9. [PMID: 27649876 DOI: 10.1016/j.ijmyco.2015.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 05/23/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- Nafees Ahmad
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Pulau Pinang, Malaysia.
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Pulau Pinang, Malaysia
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Pulau Pinang, Malaysia
| | - Arshad Javaid
- Department of Pulmonology, Postgraduate Medical Institute, Peshawar, Pakistan
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Basit A, Ahmad N, Khan AH, Javaid A, Syed Sulaiman SA, Afridi AK, Adnan AS, Haq IU, Shah SS, Ahadi A, Ahmad I. Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study. PLoS One 2014; 9:e93206. [PMID: 24705411 PMCID: PMC3976287 DOI: 10.1371/journal.pone.0093206] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/28/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Various studies have reported culture conversion at two months as a predictor of successful treatment outcome in multidrug-resistant tuberculosis (MDR-TB). OBJECTIVES The present study was conducted with the aim to evaluate the rate and predictors of culture conversion at two months in MDR-TB patients. METHODS All confirmed pulmonary MDR-TB patients enrolled for treatment at Lady Reading Hospital Peshawar, Pakistan from 1 January to 31 December 2012 and met the inclusion criteria were reviewed retrospectively. Rate and predictors of culture conversion at two months were evaluated. RESULTS Eighty seven (53.4%) out of 163 patients achieved culture conversion at two months. In a multivariate analysis lung cavitation at baseline chest X-ray (P = 0.006, OR = 0.349), resistance to ofloxacin (P = 0.041, OR = 0.193) and streptomycin (P = 0.017, OR = 0.295) had statistically significant (P<0.05) negative association with culture conversion at two months. CONCLUSION A reasonable proportion of patients achieved culture conversion at two months. Factors negatively associated with culture conversion at two months can be easily identified either before diagnosis or early in the course of MDR-TB treatment. This may help in better care of individual patients by identifying them early and treating them vigorously.
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Affiliation(s)
- Anila Basit
- Post Graduate Medical Institute, Peshawar, Pakistan
| | - Nafees Ahmad
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
| | - Arshad Javaid
- Department of Pulmonology, Lady Reading Hospital, Peshawar, Pakistan
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
| | - Afsar Khan Afridi
- Programmatic Management Unit of Drug Resistant TB, Lady Reading Hospital, Peshawar, Pakistan
| | - Azreen Syazril Adnan
- Chronic Kidney Disease (CKD) Resource Center, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Israr ul Haq
- Department of Pediatrics, Saidu Medical College, Saidu Sharif Swat, Pakistan
| | | | - Ahmed Ahadi
- Department of Pharmacy, University of Balochistan, Quetta, Pakistan
| | - Izaz Ahmad
- Department of Microbiology, Quaid-e- Azam University, Islamabad, Pakistan
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Chen J, Chen Z, Li Y, Xia W, Chen X, Chen T, Zhou L, Xu B, Xu S. Characterization of gyrA and gyrB mutations and fluoroquinolone resistance in Mycobacterium tuberculosis clinical isolates from Hubei Province, China. Braz J Infect Dis 2013; 16:136-41. [PMID: 22552454 DOI: 10.1016/s1413-8670(12)70294-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 11/17/2011] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The study aimed to investigate gyrA and gyrB mutations in Mycobacterium tuberculosis (MTB) clinical strains from 93 patients with pulmonary tuberculosis in Hubei Province, China, and analyze the association between mutation patterns of the genes and ofloxacin resistance level. RESULTS Among 93 MTB clinical isolates, 61 were ofloxacin-resistant by the proportion method, and 32 were ofloxacin-susceptible MDR-TB. No mutation in the gyrB gene was found in any MTB strains. In the 61 ofloxacin-resistant isolates, 54 mutations were observed in the gyrA gene. Only one mutation in the gyrA gene was found in ofloxacin-susceptible MDR-TB isolates. In this study, the mutation patterns of gyrA involved seven patterns of single codon mutation (A90V, S91P, S91T, D94N, D94Y, D94G or D94A) and two patterns of double codons mutation (S91P & D94H, S91P & D94A). The ofloxacin minimal inhibitory concentrations (MICs) of three patterns of single codon mutations in the gyrA gene (codons 94, 90 and 91) showed a statistically significant difference (p < 0.0001). CONCLUSIONS The gyrA mutations at codons 90, 91 and 94 constitute the primary mechanism of fluoroquinolone resistance in MTB, and mutations at codon 91 in the gyrA gene may be associated with low-level resistance to ofloxacin.
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Affiliation(s)
- Jun Chen
- School of Public, Tongji Medical College, Huazhong University of Science and Technology, Ministry of Education Key Laboratory of Environment and Health, Wuhan, China
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Amin I, Idrees M, Awan Z, Shahid M, Afzal S, Hussain A. PCR could be a method of choice for identification of both pulmonary and extra-pulmonary tuberculosis. BMC Res Notes 2011; 4:332. [PMID: 21899772 PMCID: PMC3224489 DOI: 10.1186/1756-0500-4-332] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 09/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nucleic acid amplification assays including PCR have revolutionized the detection of Mycobacterium tuberculosis (MTB). Tuberculosis spread to almost every organ of the body and is characterized on the basis of localization of infection. Therefore, different types of body fluids and tissues can be used for the detection of MTB.From 2004 to 2010 total 766 different types of smear negative samples from patients, clinically suspected for tuberculosis were received and investigated at Division of Molecular Diagnostics, University of the Punjab Lahore for the diagnosis of tuberculosis. Mycobacterial DNA was extracted followed by PCR amplification. FINDINGS A total of 356 (46.5%) samples were found positive by PCR for MTB. These included; serum (4.8%), blood (36.3%), urine (46.6%), cerebro spinal fluid (CSF) (42.1%), ascetic fluid (67.6%), pleural fluid (52%), pericardial fluid (30%), pus (38.6%), bone marrow (60%), sputum (38.8%) and bronchoalveolar lavage (BAL) (70%). Over all there was no significant difference in males and females neither in different age groups for the identification of MTB. CONCLUSION We conclude that PCR is a useful and sensitive tool for the early diagnosis of MTB in variety of clinical samples.
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Affiliation(s)
- Iram Amin
- Division of Molecular Virology & Molecular Diagnostics, National Centre of Excellence in Molecular Biology, University of the Punjab, Lahore-53500, Pakistan.
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