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Gausi K, Ignatius EH, De Jager V, Upton C, Kim S, McKhann A, Moran L, Wiesner L, von Groote-Bidlingmaier F, Marzinek P, Vanker N, Yvetot J, Pierre S, Rosenkranz SL, Swindells S, Diacon AH, Nuermberger EL, Denti P, Dooley KE. High-Dose Isoniazid Lacks EARLY Bactericidal Activity Against Isoniazid-resistant Tuberculosis Mediated by katG Mutations: A Randomized, Phase 2 Clinical Trial. Am J Respir Crit Care Med 2024. [PMID: 38564365 DOI: 10.1164/rccm.202311-2004oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
RATIONALE Observational studies suggest that high-dose isoniazid may be efficacious in treating multidrug-resistant tuberculosis (MDR-TB). However, its activity against Mycobacterium tuberculosis (M.tb) with katG mutations (which typically confer high-level resistance) is not established. OBJECTIVE To characterize early bactericidal activity (EBA) of high-dose isoniazid in patients with tuberculosis caused by katG-mutated M.tb. METHODS A5312 was a Phase 2A randomized, open-label trial. Participants with tuberculosis caused by katG-mutated M.tb were randomized to receive 15 or 20 mg/kg isoniazid daily for 7 days. Daily sputum samples were collected for quantitative culture. Intensive PK sampling was performed on day 6. Data were pooled across all A5312 participants for analysis (drug-sensitive, inhA-mutated, and katG-mutated M.tb). EBA was determined using nonlinear mixed-effects modelling. RESULTS Of 80 treated participants, 21 had katG-mutated M.tb. Isoniazid PK was best described by a two-compartment model with an effect of NAT2 acetylator phenotype on clearance. Model-derived Cmax and AUC in the 15 and 20 mg/kg groups were 15.0 and 22.1 mg/L and 57.6 and 76.8 mg∙h/L, respectively. Isoniazid bacterial kill was described using an effect compartment and a sigmoidal Emax relationship. Isoniazid potency against katG-mutated M.tb was approximately 10-fold lower than against inhA-mutated M.tb. The highest dose (20 mg/kg) did not demonstrate measurable EBA, except in a subset of slow NAT2 acetylators (who experienced the highest concentrations). There were no grade 3 or higher drug-related adverse events. CONCLUSIONS This study found negligible bactericidal activity of high-dose isoniazid (15-20 mg/kg) in the majority of participants with tuberculosis caused by katG-mutated M.tb. Clinical trial registration available at www. CLINICALTRIALS gov, ID: NCT01936831.
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Affiliation(s)
- Kamunkhwala Gausi
- University of Cape Town, 37716, Department of Medicine, Observatory, Western Cape, South Africa
- South Africa
| | | | - Veronique De Jager
- TASK Applied Science, TASK Clinical Research Centre, Cape Town, South Africa
| | | | - Soyeon Kim
- Frontier Science Foundation, 2402, Brookline, Massachusetts, United States
| | - Ashley McKhann
- Harvard T.H. Chan School of Public Health, Boston, United States
| | - Laura Moran
- Social & Scientific Systems Inc, 43740, Silver Spring, Maryland, United States
| | - Lubbe Wiesner
- University of Cape Town Faculty of Health Sciences, 63726, Observatory, Western Cape, South Africa
| | | | - Philip Marzinek
- Frontier Science Foundation, 2402, Amherst, New York, United States
| | | | - Joseph Yvetot
- GHESKIO Centers, Port-au-Prince, Haïti;, Port-au-Prince, Haiti
| | | | - Susan L Rosenkranz
- Harvard University T H Chan School of Public Health, 1857, Boston, Massachusetts, United States
- Frontier Science and Technology Research Foundation, 2402, Boston, Massachusetts, United States
| | | | | | | | - Paolo Denti
- University of Cape Town Faculty of Health Sciences, 63726, Observatory, Western Cape, South Africa;
| | - Kelly E Dooley
- Vanderbilt University Medical Center, 12328, Medicine, Nashville, Tennessee, United States
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Kontsevaya I, Heyckendorf J, Koops F, Hillemann D, Goldmann T, Upton CM, De Jager V, Diacon A, Lange C. Transrenal Mycobacterium tuberculosis DNA in pulmonary tuberculosis patients during the first 14 days of treatment. Microbiol Spectr 2023; 11:e0234823. [PMID: 37882572 PMCID: PMC10714760 DOI: 10.1128/spectrum.02348-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/11/2023] [Indexed: 10/27/2023] Open
Abstract
IMPORTANCE This study presents the results of the evaluation of a novel method for the detection of Mycobacterium tuberculosis, the causative agent of tuberculosis, in urine. Detecting parts of the mycobacteria in urine is of particular interest as it allows us to use a sample that is easy to obtain and that does not require uncomfortable procedures or safety precautions like obtaining sputum for culture, which is the most commonly used sample in the diagnosis of tuberculosis. In certain groups of individuals who cannot produce sputum, for example, children, non-sputum-based methods have particular importance. We found that the method tested was able to detect bacterial killing by active antibiotics that disrupt the cell wall and lead to fragmentation of bacteria. However, the assay can't detect inactive bacteria or bacteria that are active with an intact cell wall.
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Affiliation(s)
- Irina Kontsevaya
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Borstel, Germany
- Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jan Heyckendorf
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frauke Koops
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Borstel, Germany
| | - Doris Hillemann
- National Reference Center, Research Center Borstel, Borstel, Germany
| | - Torsten Goldmann
- Division of Histology, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- Airway Research Center North, Member of the German Center for Lung Research, Großhansdorf, Germany
| | | | | | | | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Borstel, Germany
- Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine, Houston, Texas, USA
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De Jager V, Gupte N, Nunes S, Barnes GL, van Wijk RC, Mostert J, Dorman SE, Abulfathi AA, Upton CM, Faraj A, Nuermberger EL, Lamichhane G, Svensson EM, Simonsson USH, Diacon AH, Dooley KE. Early Bactericidal Activity of Meropenem plus Clavulanate (with or without Rifampin) for Tuberculosis: The COMRADE Randomized, Phase 2A Clinical Trial. Am J Respir Crit Care Med 2022; 205:1228-1235. [PMID: 35258443 PMCID: PMC9872811 DOI: 10.1164/rccm.202108-1976oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Rationale: Carbapenems are recommended for treatment of drug-resistant tuberculosis. Optimal dosing remains uncertain. Objectives: To evaluate the 14-day bactericidal activity of meropenem, at different doses, with or without rifampin. Methods: Individuals with drug-sensitive pulmonary tuberculosis were randomized to one of four intravenous meropenem-based arms: 2 g every 8 hours (TID) (arm C), 2 g TID plus rifampin at 20 mg/kg once daily (arm D), 1 g TID (arm E), or 3 g once daily (arm F). All participants received amoxicillin/clavulanate with each meropenem dose. Serial overnight sputum samples were collected from baseline and throughout treatment. Median daily fall in colony-forming unit (CFU) counts per milliliter of sputum (solid culture) (EBACFU0-14) and increase in time to positive culture (TTP) in liquid media were estimated with mixed-effects modeling. Serial blood samples were collected for pharmacokinetic analysis on Day 13. Measurements and Main Results: Sixty participants enrolled. Median EBACFU0-14 counts (2.5th-97.5th percentiles) were 0.22 (0.12-0.33), 0.12 (0.057-0.21), 0.059 (0.033-0.097), and 0.053 (0.035-0.081); TTP increased by 0.34 (0.21-0.75), 0.11 (0.052-0.37), 0.094 (0.034-0.23), and 0.12 (0.04-0.41) (log10 h), for arms C-F, respectively. Meropenem pharmacokinetics were not affected by rifampin coadministration. Twelve participants withdrew early, many of whom cited gastrointestinal adverse events. Conclusions: Bactericidal activity was greater with the World Health Organization-recommended total daily dose of 6 g daily than with a lower dose of 3 g daily. This difference was only detectable with solid culture. Tolerability of intravenous meropenem, with amoxicillin/clavulanate, though, was poor at all doses, calling into question the utility of this drug in second-line regimens. Clinical trial registered with www.clinicaltrials.gov (NCT03174184).
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Affiliation(s)
| | - Nikhil Gupte
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland;,Johns Hopkins India, Pune, India
| | | | - Grace L. Barnes
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Susan E. Dorman
- Medical University of South Carolina, Charleston, South Carolina
| | - Ahmed A. Abulfathi
- Department of Medicine, Stellenbosch University, Cape Town, South Africa;,Department of Clinical Pharmacology and Therapeutics, University of Maiduguri, Maiduguri, Nigeria; and
| | | | - Alan Faraj
- Department of Pharmaceutical Biosciences and
| | - Eric L. Nuermberger
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gyanu Lamichhane
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elin M. Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden;,Department of Pharmacy, Radboud University, Njimegen, the Netherlands
| | | | | | - Kelly E. Dooley
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Brown GD, Meintjes G, Kolls JK, Gray C, Horsnell W, Achan B, Alber G, Aloisi M, Armstrong-James D, Beale M, Bicanic T, Black J, Bohjanen P, Botes A, Boulware DR, Brown G, Bunjun R, Carr W, Casadevall A, Chang C, Chivero E, Corcoran C, Cross A, Dawood H, Day J, De Bernardis F, De Jager V, De Repentigny L, Denning D, Eschke M, Finkelman M, Govender N, Gow N, Graham L, Gryschek R, Hammond-Aryee K, Harrison T, Heard N, Hill M, Hoving JC, Janoff E, Jarvis J, Kayuni S, King K, Kolls J, Kullberg BJ, Lalloo DG, Letang E, Levitz S, Limper A, Longley N, Machiridza TR, Mahabeer Y, Martinsons N, Meiring S, Meya D, Miller R, Molloy S, Morris L, Mukaremera L, Musubire AK, Muzoora C, Nair A, Nakiwala Kimbowa J, Netea M, Nielsen K, O'hern J, Okurut S, Parker A, Patterson T, Pennap G, Perfect J, Prinsloo C, Rhein J, Rolfes MA, Samuel C, Schutz C, Scriven J, Sebolai OM, Sojane K, Sriruttan C, Stead D, Steyn A, Thawer NK, Thienemann F, Von Hohenberg M, Vreulink JM, Wessels J, Wood K, Yang YL. AIDS-related mycoses: the way forward. Trends Microbiol 2014; 22:107-9. [PMID: 24581941 DOI: 10.1016/j.tim.2013.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/06/2013] [Accepted: 12/18/2013] [Indexed: 11/30/2022]
Abstract
The contribution of fungal infections to the morbidity and mortality of HIV-infected individuals is largely unrecognized. A recent meeting highlighted several priorities that need to be urgently addressed, including improved epidemiological surveillance, increased availability of existing diagnostics and drugs, more training in the field of medical mycology, and better funding for research and provision of treatment, particularly in developing countries.
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Affiliation(s)
- Gordon D Brown
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa; Aberdeen Fungal Group, University of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Jay K Kolls
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Clive Gray
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - William Horsnell
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
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