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Cevik M, Thompson LC, Upton C, Rolla VC, Malahleha M, Mmbaga B, Ngubane N, Abu Bakar Z, Rassool M, Variava E, Dawson R, Staples S, Lalloo U, Louw C, Conradie F, Eristavi M, Samoilova A, Skornyakov SN, Ntinginya NE, Haraka F, Praygod G, Mayanja-Kizza H, Caoili J, Balanag V, Dalcolmo MP, McHugh T, Hunt R, Solanki P, Bateson A, Crook AM, Fabiane S, Timm J, Sun E, Spigelman M, Sloan DJ, Gillespie SH. Bedaquiline-pretomanid-moxifloxacin-pyrazinamide for drug-sensitive and drug-resistant pulmonary tuberculosis treatment: a phase 2c, open-label, multicentre, partially randomised controlled trial. Lancet Infect Dis 2024:S1473-3099(24)00223-8. [PMID: 38768617 DOI: 10.1016/s1473-3099(24)00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The current tuberculosis (TB) drug development pipeline is being re-populated with candidates, including nitroimidazoles such as pretomanid, that exhibit a potential to shorten TB therapy by exerting a bactericidal effect on non-replicating bacilli. Based on results from preclinical and early clinical studies, a four-drug combination of bedaquiline, pretomanid, moxifloxacin, and pyrazinamide (BPaMZ) regimen was identified with treatment-shortening potential for both drug-susceptible (DS) and drug-resistant (DR) TB. This trial aimed to determine the safety and efficacy of BPaMZ. We compared 4 months of BPaMZ to the standard 6 months of isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) in DS-TB. 6 months of BPaMZ was assessed in DR-TB. METHODS SimpliciTB was a partially randomised, phase 2c, open-label, clinical trial, recruiting participants at 26 sites in eight countries. Participants aged 18 years or older with pulmonary TB who were sputum smear positive for acid-fast bacilli were eligible for enrolment. Participants with DS-TB had Mycobacterium tuberculosis with sensitivity to rifampicin and isoniazid. Participants with DR-TB had M tuberculosis with resistance to rifampicin, isoniazid, or both. Participants with DS-TB were randomly allocated in a 1:1 ratio, stratified by HIV status and cavitation on chest radiograph, using balanced block randomisation with a fixed block size of four. The primary efficacy endpoint was time to sputum culture-negative status by 8 weeks; the key secondary endpoint was unfavourable outcome at week 52. A non-inferiority margin of 12% was chosen for the key secondary outcome. Safety and tolerability outcomes are presented as descriptive analyses. The efficacy analysis population contained patients who received at least one dose of medication and who had efficacy data available and had no major protocol violations. The safety population contained patients who received at least one dose of medication. This study is registered with ClinicalTrials.gov (NCT03338621) and is completed. FINDINGS Between July 30, 2018, and March 2, 2020, 455 participants were enrolled and received at least one dose of study treatment. 324 (71%) participants were male and 131 (29%) participants were female. 303 participants with DS-TB were randomly assigned to 4 months of BPaMZ (n=150) or HRZE (n=153). In a modified intention-to-treat (mITT) analysis, by week 8, 122 (84%) of 145 and 70 (47%) of 148 participants were culture-negative on 4 months of BPaMZ and HRZE, respectively, with a hazard ratio for earlier negative status of 2·93 (95% CI 2·17-3·96; p<0·0001). Median time to negative culture (TTN) was 6 weeks (IQR 4-8) on 4 months of BPaMZ and 11 weeks (6-12) on HRZE. 86% of participants with DR-TB receiving 6 months of BPaMZ (n=152) reached culture-negative status by week 8, with a median TTN of 5 weeks (IQR 3-7). At week 52, 120 (83%) of 144, 134 (93%) of 144, and 111 (83%) of 133 on 4 months of BPaMZ, HRZE, and 6 months of BPaMZ had favourable outcomes, respectively. Despite bacteriological efficacy, 4 months of BPaMZ did not meet the non-inferiority margin for the key secondary endpoint in the pre-defined mITT population due to higher withdrawal rates for adverse hepatic events. Non-inferiority was demonstrated in the per-protocol population confirming the effect of withdrawals with 4 months of BPaMZ. At least one liver-related treatment-emergent adverse effect (TEAE) occurred among 45 (30%) participants on 4 months of BPaMZ, 38 (25%) on HRZE, and 33 (22%) on 6 months of BPaMZ. Serious liver-related TEAEs were reported by 20 participants overall; 11 (7%) among those on 4 months of BPaMZ, one (1%) on HRZE, and eight (5%) on 6 months of BPaMZ. The most common reasons for discontinuation of trial treatment were hepatotoxicity (ten participants [2%]), increased hepatic enzymes (nine participants [2%]), QTcF prolongation (three participants [1%]), and hypersensitivity (two participants [<1%]). INTERPRETATION For DS-TB, BPaMZ successfully met the primary efficacy endpoint of sputum culture conversion. The regimen did not meet the key secondary efficacy endpoint due to adverse events resulting in treatment withdrawal. Our study demonstrated the potential for treatment-shortening efficacy of the BPaMZ regimen for DS-TB and DR-TB, providing clinical validation of a murine model widely used to identify such regimens. It also highlights that novel, treatment-shortening TB treatment regimens require an acceptable toxicity and tolerability profile with minimal monitoring in low-resource and high-burden settings. The increased risk of unpredictable severe hepatic adverse events with 4 months of BPaMZ would be a considerable obstacle to implementation of this regimen in settings with high burdens of TB with limited infrastructure for close surveillance of liver biochemistry. Future research should focus on improving the preclinical and early clinical detection and mitigation of safety issues together and further efforts to optimise shorter treatments. FUNDING TB Alliance.
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Affiliation(s)
- Muge Cevik
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK.
| | | | | | | | | | | | | | | | | | | | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Cheryl Louw
- Madibeng Centre for Research, Brits, South Africa
| | - Francesca Conradie
- Reproductive Health and HIV Research Unit (RHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Marika Eristavi
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Anastasia Samoilova
- Research Institute of Phthisiopulmonology of IM Sechenov First Moscow State Medical University, Moscow, Russia
| | - Sergey N Skornyakov
- Ural Research Institute for Phthisiopulmonology, National Medical Research Center of Tuberculosis and Infectious Diseases of Ministry of Health of the Russian Federation, Yekaterinburg, Russia
| | | | | | | | | | - Janice Caoili
- Tropical Disease Foundation, Makati City, Manila, Philippines
| | | | | | - Timothy McHugh
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Robert Hunt
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Priya Solanki
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Anna Bateson
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Angela M Crook
- MRC Clinical Trials Unit, University College London, London, UK
| | - Stella Fabiane
- MRC Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Derek J Sloan
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK
| | - Stephen H Gillespie
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK
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Shah NS, Kityo C, Hughes MD, McCarthy C, Wallis C, Hosseinipour M, Langat D, Nyirenda M, Rassool M, Dawson R, Joseph Y, Some F, Mngqbisa R, Mukwekwerere PG, Woolley E, Godfrey C, Manabe YC, Mellors JW, Flexner C, Maartens G. Effectiveness of double-dose dolutegravir in people receiving rifampin-based tuberculosis treatment: an observational, cohort study of people with HIV from six countries. Clin Infect Dis 2024:ciae269. [PMID: 38739755 DOI: 10.1093/cid/ciae269] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/29/2024] [Accepted: 05/09/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Tenofovir-lamivudine-dolutegravir (TLD) is the preferred first-line antiretroviral therapy (ART) regimen. An additional 50 mg dose of dolutegravir (TLD + 50) is required with rifampin-containing tuberculosis (TB) co-treatment. There are limited data on the effectiveness of TLD + 50 in individuals with TB/HIV. METHODS Prospective, observational cohort study at 12 sites in Haiti, Kenya, Malawi, South Africa, Uganda, Zimbabwe. Participants starting TLD and rifampin-containing TB treatment were eligible. Primary outcome was HIV-1 RNA ≤1000 copies/mL at end of TB treatment. FINDINGS We enrolled 91 participants with TB/HIV: 75 (82%) ART-naïve participants starting TLD after a median 15 days on TB treatment, 10 (11%) ART-naïve participants starting TLD and TB treatment, 5 (5%) starting TB treatment after a median 3.3 years on TLD, and 1 (1%) starting TB treatment and TLD after changing from efavirenz/lamivudine/tenofovir. Median age was 37 years, 35% female, median CD4 count 120 cells/mm3 (IQR 50-295), 87% had HIV-1 RNA >1000 copies/mL. Two participants died during TB treatment. Among 89 surviving participants, 80 were followed to TB treatment completion, including 7 who had no HIV-1 RNA result due to missed visits. Primary virologic outcome was assessed in 73 participants, of whom 69 (95%, 95% CI 89-100%) had HIV-1 RNA ≤1000 copies/mL. No dolutegravir resistance mutations were detected among four participants with HIV-1 RNA >1000 copies/mL. INTERPRETATION In routine programmatic settings, concurrent rifampin-containing TB treatment and TLD + 50 was feasible, well-tolerated, and achieved high rates of viral suppression in a cohort of predominantly ART-naïve people with TB/HIV.
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Affiliation(s)
- N Sarita Shah
- Emory Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | | | | | - Carole Wallis
- Lancet Laboratories and BARC-SA, Johannesburg, South Africa
| | | | | | - Mulinda Nyirenda
- College of Medicine- Johns Hopkins Research Project, Blantyre, Malawi
| | - Mohammed Rassool
- Clinical HIV Research Unit, Helen Joseph Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rodney Dawson
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yvetot Joseph
- GHESKIO Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | - Fatma Some
- Moi University Clinical Research Centre, Eldoret, Kenya
| | | | | | - Elizabeth Woolley
- Social & Scientific Systems, Inc., A DLH Holdings Company, Silver Spring, MD, USA
| | - Catherine Godfrey
- Office of the Global AIDS Coordinator, U.S. Department of State, Washington DC, USA
| | - Yukari C Manabe
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Charles Flexner
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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3
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Podany AT, Cramer Y, Imperial M, Rosenkranz SL, Avihingsanon A, Arduino R, Samaneka W, Gelmanova I, Savic R, Swindells S, Dawson R, Luetkemeyer AF. Twice-Daily Dolutegravir Based Antiretroviral Therapy with One Month of Daily Rifapentine and Isoniazid (1HP) for TB Prevention. Clin Infect Dis 2024:ciae183. [PMID: 38568956 DOI: 10.1093/cid/ciae183] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/16/2024] [Accepted: 03/24/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND One month of daily rifapentine + isoniazid (1HP) is an effective, ultrashort option for TB prevention in people with HIV (PWH). However, rifapentine may decrease antiretroviral drug concentrations and increase the risk of virologic failure. ACTG A5372 evaluated the effect of 1HP on the pharmacokinetics of twice daily dolutegravir. METHODS A5372 was a multicenter, pharmacokinetic study in PWH (≥18 years) already on dolutegravir-containing antiretroviral therapy with HIV RNA < 50 copies/mL. Participants received daily rifapentine/isoniazid (600mg/300mg) for 28 days as part of 1HP. Dolutegravir was increased to 50mg twice daily during 1HP and intensive pharmacokinetic sampling was performed on day 0 (before 1HP) and on the final day of 1HP treatment. RESULTS Thirty-two participants (41% female; 66% Black/African; median (Q1, Q3) age 42 (34, 49) years) were included in the pharmacokinetic analysis. Thirty-one of 32 had HIV RNA levels <50 copies/mL at the end of 1HP dosing. One participant had an HIV RNA of 160 copies/mL at day 28, with HIV RNA <50 copies/mL upon repeat testing on day 42. The median (Q1, Q3) dolutegravir trough concentration was 1751 ng/mL (1195, 2542) on day 0 vs. 1987ng/mL (1331, 2278) on day 28 (day 28:day 0 GMR 1.05, [90% CI 0.93-1.2]; p = 0.43). No serious adverse events were reported. CONCLUSION Dolutegravir trough concentrations with 50mg twice daily dosing during 1HP treatment were greater than those with standard dose dolutegravir once daily without 1HP. These pharmacokinetic, virologic, and safety data provide support for twice daily dolutegravir use in combination with 1HP for TB prevention.
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Affiliation(s)
- Anthony T Podany
- University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA
| | - Yoninah Cramer
- Harvard School of Public Health, Statistical & Data Analysis Center, Boston, MA, USA
| | - Marjorie Imperial
- University of California San Francisco, College of Pharmacy, San Francisco, CA, USA
| | - Susan L Rosenkranz
- Harvard School of Public Health, Statistical & Data Analysis Center, Boston, MA, USA
| | | | - Roberto Arduino
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Wadzanai Samaneka
- University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Irina Gelmanova
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Rada Savic
- University of California San Francisco, College of Pharmacy, San Francisco, CA, USA
| | - Susan Swindells
- University of Nebraska Medical Center, Infectious Diseases, Internal Medicine, Omaha, NE, USA
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - Anne F Luetkemeyer
- University of California San Francisco, College of Medicine, San Francisco, CA, USA
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Tait D, Diacon A, Borges ÁH, van Brakel E, Hokey D, Rutkowski KT, Hunt DJ, Russell M, Andersen PL, Kromann I, Ruhwald M, Churchyard G, Dawson R. Safety and immunogenicity of the H56:IC31 tuberculosis vaccine candidate in adults successfully treated for drug-susceptible pulmonary TB: a phase 1 randomized trial. J Infect Dis 2024:jiae170. [PMID: 38557639 DOI: 10.1093/infdis/jiae170] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND H56:IC31 is a candidate vaccine against tuberculosis (TB) with the potential to reduce TB recurrence rate. It is thus important for future clinical trials to demonstrate safety and immunogenicity of H56:IC31 in individuals treated for TB. METHODS 22 adults confirmed to be Mtb negative (by 2 GeneXpert tests or 2 sputum cultures) after four-five months of TB treatment, and not more than 28 days after completion of TB treatment, were randomized to receive two doses of H56:IC31 (5 mg H56:500 nmol IC31; N=16) or placebo (N=6) 56 days apart. Participants were followed for 420 days for safety and immunogenicity. RESULTS H56:IC31 vaccination was associated with an acceptable safety profile, consisting mostly of mild self-limited injection site reactions. No serious adverse events, and no vaccine-related severe adverse events, were reported. H56:IC31 induced a CD4+ T-cell response for Ag85B and ESAT-6, with ESAT-6 being immunodominant, which persisted through six months after the last vaccination. There was some evidence of CD8+ T-cell responses for both Ag85B and ESAT-6, but to a lesser extent than CD4+ responses. CONCLUSIONS H56:IC31 was associated with an acceptable safety profile, and induced a predominant CD4+ T-cell response, in adults recently treated for drug-susceptible, uncomplicated pulmonary TB. TRIAL REGISTRATION ClinicalTrials.gov, NCT02375698.
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Affiliation(s)
- Dereck Tait
- Independent Consultant, Cape Town, South Africa
| | | | - Álvaro H Borges
- Department of Infectious Disease Immunology, Statens Serum Institut, Copenhagen, Denmark
| | | | | | | | | | | | - Peter L Andersen
- Novo Nordisk Foundation, Hellerup, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Ingrid Kromann
- Department of Vaccine Development, Statens Serum Institut, Copenhagen, Denmark
| | - Morten Ruhwald
- Department of Infectious Disease Immunology, Statens Serum Institut, Copenhagen, Denmark
- Foundation of Innovative New Diagnostics, Geneva, Switzerland
| | - Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Rodney Dawson
- University of Cape Town Lung Institute, Centre for Tuberculosis Research Innovation, Cape Town, South Africa
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5
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Ngo HX, Xu AY, Velásquez GE, Zhang N, Chang VK, Kurbatova EV, Whitworth WC, Sizemore E, Bryant K, Carr W, Weiner M, Dooley KE, Engle M, Dorman SE, Nahid P, Swindells S, Chaisson RE, Nsubuga P, Lourens M, Dawson R, Savic RM. Pharmacokinetic-Pharmacodynamic Evidence from a Phase 3 Trial to Support Flat-Dosing of Rifampicin for Tuberculosis. Clin Infect Dis 2024:ciae119. [PMID: 38462673 DOI: 10.1093/cid/ciae119] [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: 11/09/2023] [Revised: 02/23/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND The optimal dosing strategy for rifampicin in treating drug-susceptible tuberculosis (TB) is still highly debated. In the Phase 3 clinical trial Study 31/ACTG 5349 (NCT02410772), all participants in the control regimen arm received 600 mg rifampicin daily as a flat dose. Here, we evaluated relationships between rifampicin exposure and efficacy and safety outcomes. METHODS We analyzed rifampicin concentration time profiles using population nonlinear mixed-effects models. We compared simulated rifampicin exposure from flat- and weight-banded dosing. We evaluated the effect of rifampicin exposure on stable culture conversion at 6 months, TB-related unfavorable outcomes at 9, 12, and 18 months using Cox proportional hazard models, and all trial-defined safety outcomes using logistic regression. RESULTS Our model derived rifampicin exposure ranged from 4.57 mg·h/L to 140.0 mg·h/L with a median of 41.8 mg·h/L. Pharmacokinetic simulations demonstrated that flat-dosed rifampicin provided exposure coverage similar to weight-banded dose. Exposure-efficacy analysis (N=680) showed that participants with rifampicin exposure below the median experienced similar hazards of stable culture conversion and TB-related unfavorable outcomes compared to those with exposure above the median. Exposure-safety analysis (N=722) showed that increased rifampicin exposure was not associated with increased grade 3 or higher adverse events, or serious adverse events. CONCLUSIONS Flat-dosing of rifampicin at 600 mg daily may be a reasonable alternative to the incumbent weight-banded dosing strategy for the standard of care 6-month regimen. Future research should assess the optimal dosing strategy for rifampicin, at doses higher than the current recommendation.
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Affiliation(s)
- Huy X Ngo
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Ava Y Xu
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Bakar Computational Health Sciences Institute, University of California, San Francisco, California
| | - Gustavo E Velásquez
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, California, United States of America
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Nan Zhang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Vincent K Chang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Ekaterina V Kurbatova
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - William C Whitworth
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Erin Sizemore
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kia Bryant
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Wendy Carr
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Marc Weiner
- University of Texas Health Science Center at San Antonio and the South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Kelly E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Melissa Engle
- University of Texas Health Science Center at San Antonio and the South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Susan E Dorman
- Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Payam Nahid
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States of America
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, California, United States of America
| | - Susan Swindells
- University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Richard E Chaisson
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Pheona Nsubuga
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Madeleine Lourens
- TASK Applied Science CRS, Brooklyn Chest Hospital, Bellville, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States of America
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, California, United States of America
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Dawson R, Diacon AH, Takuva S, Liu Y, Zheng B, Karwe V, Hafkin J. Quabodepistat in combination with delamanid and bedaquiline in participants with drug-susceptible pulmonary tuberculosis: protocol for a multicenter, phase 2b/c, open-label, randomized, dose-finding trial to evaluate safety and efficacy. Trials 2024; 25:70. [PMID: 38243296 PMCID: PMC10799444 DOI: 10.1186/s13063-024-07912-5] [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: 10/19/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Delamanid and bedaquiline are two of the most recently developed antituberculosis (TB) drugs that have been extensively studied in patients with multidrug-resistant TB. There is currently a need for more potent, less-toxic drugs with novel mechanisms of action that can be used in combination with these newer agents to shorten the duration of treatment as well as prevent the development of drug resistance. Quabodepistat (QBS) is a newly discovered inhibitor of decaprenylphosphoryl-β-D-ribose-2'-oxidase, an essential enzyme for Mycobacterium tuberculosis to synthesize key components of its cell wall. The objective of this study is to evaluate the safety, efficacy, and appropriate dosing of a 4-month regimen of QBS in combination with delamanid and bedaquiline in participants with drug-susceptible pulmonary TB in comparison with the 6-month standard treatment (i.e., rifampicin, isoniazid, ethambutol, and pyrazinamide). METHODS This phase 2b/c, open-label, randomized, parallel group, dose-finding trial will enroll approximately 120 participants (including no more than 15% with human immunodeficiency virus [HIV] coinfection) aged ≥ 18 to ≤ 65 years at screening with newly diagnosed pulmonary drug-sensitive TB from ~8 sites in South Africa. Following a screening period of up to 14 days, eligible participants will be randomized in a ratio of 1:2:2:1 to one of four arms. Randomization will be stratified by HIV status and the presence of bilateral cavitation on a screening chest x-ray. After the end of the treatment period, participants will be followed until 12 months post randomization. The primary efficacy endpoint is the proportion of participants achieving sputum culture conversion in Mycobacteria Growth Indicator Tube by the end of the treatment period. The safety endpoints consist of adverse events, clinical laboratory tests, vital signs, physical examination findings, and electrocardiographic changes. DISCUSSION QBS's potent bactericidal activity and distinct mechanism of action (compared with other TB drugs currently available for human use) may make it an ideal candidate for inclusion in a novel treatment regimen to improve efficacy and potentially prevent resistance to concomitant TB drugs. This trial will assess the effectiveness, safety, and dosing of a new, shorter, QBS-based, combination anti-TB treatment regimen. TRIAL STATUS ClinicalTrials.gov NCT05221502. Registered on February 3, 2022.
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Affiliation(s)
- Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Andreas H Diacon
- Department of Medicine, Stellenbosch University, Cape Town, South Africa
- TASK Applied Science, Cape Town, South Africa
| | - Simbarashe Takuva
- Otsuka Novel Products GmbH, Munich, Germany
- Faculty of Health Sciences, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Yongge Liu
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | - Bo Zheng
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | - Vatsala Karwe
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | - Jeffrey Hafkin
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA.
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Stemkens R, de Jager V, Dawson R, Diacon AH, Narunsky K, Padayachee SD, Boeree MJ, van Beek SW, Colbers A, Coenen MJH, Svensson EM, Fuhr U, Phillips PPJ, te Brake LHM, Aarnoutse RE. Drug interaction potential of high-dose rifampicin in patients with pulmonary tuberculosis. Antimicrob Agents Chemother 2023; 67:e0068323. [PMID: 37768317 PMCID: PMC10583668 DOI: 10.1128/aac.00683-23] [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: 05/25/2023] [Accepted: 07/27/2023] [Indexed: 09/29/2023] Open
Abstract
Accumulating evidence supports the use of higher doses of rifampicin for tuberculosis (TB) treatment. Rifampicin is a potent inducer of metabolic enzymes and drug transporters, resulting in clinically relevant drug interactions. To assess the drug interaction potential of higher doses of rifampicin, we compared the effect of high-dose rifampicin (40 mg/kg daily, RIF40) and standard-dose rifampicin (10 mg/kg daily, RIF10) on the activities of major cytochrome P450 (CYP) enzymes and P-glycoprotein (P-gp). In this open-label, single-arm, two-period, fixed-order phenotyping cocktail study, adult participants with pulmonary TB received RIF10 (days 1-15), followed by RIF40 (days 16-30). A single dose of selective substrates (probe drugs) was administered orally on days 15 and 30: caffeine (CYP1A2), tolbutamide (CYP2C9), omeprazole (CYP2C19), dextromethorphan (CYP2D6), midazolam (CYP3A), and digoxin (P-gp). Intensive pharmacokinetic blood sampling was performed over 24 hours after probe drug intake. In all, 25 participants completed the study. Geometric mean ratios (90% confidence interval) of the total exposure (area under the concentration versus time curve, RIF40 versus RIF10) for each of the probe drugs were as follows: caffeine, 105% (96%-115%); tolbutamide, 80% (74%-86%); omeprazole, 55% (47%-65%); dextromethorphan, 77% (68%-86%); midazolam, 62% (49%-78%), and 117% (105%-130%) for digoxin. In summary, high-dose rifampicin resulted in no additional effect on CYP1A2, mild additional induction of CYP2C9, CYP2C19, CYP2D6, and CYP3A, and marginal inhibition of P-gp. Existing recommendations on managing drug interactions with rifampicin can remain unchanged for the majority of co-administered drugs when using high-dose rifampicin. Clinical Trials registration number NCT04525235.
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Affiliation(s)
- Ralf Stemkens
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Rodney Dawson
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Kim Narunsky
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Sherman D. Padayachee
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Martin J. Boeree
- Department of Pulmonary Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stijn W. van Beek
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke J. H. Coenen
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elin M. Svensson
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Uwe Fuhr
- />Clinical Pharmacology, Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Lindsey H. M. te Brake
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob E. Aarnoutse
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - on behalf of the PanACEA consortium
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- TASK, Cape Town, South Africa
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Pulmonary Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- />Clinical Pharmacology, Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- UCSF Center for Tuberculosis, University of California, San Francisco, California, USA
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8
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Krishnan S, Wu X, Kim S, McIntire K, Naini L, Hughes MD, Dawson R, Mave V, Gaikwad S, Sanchez J, Mendoza-Ticona A, Gonzales P, Comins K, Shenje J, Fontain SN, Omozoarhe A, Mohapi L, Lalloo UG, Garcia Ferreira AC, Mugah C, Harrington M, Shah NS, Hesseling AC, Churchyard G, Swindells S, Gupta A. 1-Year Incidence of Tuberculosis Infection and Disease Among Household Contacts of Rifampin- and Multidrug-Resistant Tuberculosis. Clin Infect Dis 2023; 77:892-900. [PMID: 37227925 PMCID: PMC10681643 DOI: 10.1093/cid/ciad301] [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: 02/16/2023] [Revised: 04/24/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Tuberculosis infection (TBI) and TB disease (TBD) incidence remains poorly described following household contact (HHC) rifampin-/multidrug-resistant TB exposure. We sought to characterize TBI and TBD incidence at 1 year in HHCs and to evaluate TB preventive treatment (TPT) use in high-risk groups. METHODS We previously conducted a cross-sectional study of HHCs with rifampin-/multidrug-resistant TB in 8 high-burden countries and reassessed TBI (interferon-gamma release assay, HHCs aged ≥5 years) and TBD (HHCs all ages) at 1 year. Incidence was estimated across age and risk groups (<5 years; ≥5 years, diagnosed with human immunodeficiency virus [HIV]; ≥5 years, not diagnosed with HIV/unknown, baseline TBI-positive) by logistic or log-binomial regression fitted using generalized estimating equations. RESULTS Of 1016 HHCs, 850 (83.7%) from 247 households were assessed (median, 51.4 weeks). Among 242 HHCs, 52 tested interferon-gamma release assay-positive, yielding a 1-year 21.6% (95% confidence interval [CI], 16.7-27.4) TBI cumulative incidence. Sixteen of 742 HHCs developed confirmed (n = 5), probable (n = 3), or possible (n = 8) TBD, yielding a 2.3% (95% CI, 1.4-3.8) 1-year cumulative incidence (1.1%; 95% CI, .5-2.2 for confirmed/probable TBD). TBD relative risk was 11.5-fold (95% CI, 1.7-78.7), 10.4-fold (95% CI, 2.4-45.6), and 2.9-fold (95% CI, .5-17.8) higher in age <5 years, diagnosed with HIV, and baseline TBI high-risk groups, respectively, vs the not high-risk group (P = .0015). By 1 year, 4% (21 of 553) of high-risk HHCs had received TPT. CONCLUSIONS TBI and TBD incidence continued through 1 year in rifampin-/multidrug-resistant TB HHCs. Low TPT coverage emphasizes the need for evidence-based prevention and scale-up, particularly among high-risk groups.
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Affiliation(s)
- Sonya Krishnan
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xingye Wu
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Soyeon Kim
- Frontier Science Foundation, Brookline, Massachusetts, USA
| | - Katie McIntire
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Linda Naini
- Social & Scientific Systems, Silver Spring, Maryland, USA
| | - Michael D Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rodney Dawson
- University of Cape Town Lung Institute and Department of Medicine, Cape Town, South Africa
| | - Vidya Mave
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Jorge Sanchez
- Centro de Investigaciones Biomedicas y Medioambientales (CITBM), Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Pedro Gonzales
- Asociació n Civil Impacta Salud y Educació n, Lima, Peru
| | - Kyla Comins
- TASK Applied Science Clinical Research Site, Bellville, South Africa
| | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - Sandy Nerette Fontain
- GHESKIO Centers Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | - Ayotunde Omozoarhe
- Botswana Harvard AIDS Institute Partnership CTU, Gaborone Clinical Research Site, Gaborone, Botswana
| | - Lerato Mohapi
- Soweto Clinical Research Site, University of the Witwatersrand, Johannesburg, South Africa
| | - Umesh G Lalloo
- Durban International Clinical Research Site, Durban University of Technology, Durban, South Africa
| | | | | | | | - N Sarita Shah
- Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Gavin Churchyard
- Aurum Institute, Parktown, South Africa
- University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
- Advancing Care and Treatment, South African Medical Research Council, Johannesburg, South Africa
| | - Susan Swindells
- Department of Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Amita Gupta
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Byramjee Jeejeebhoy Government Medical College, Pune, India
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9
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Dawson R, Diacon AH, Narunsky K, De Jager VR, Stinson KW, Zhang X, Liu Y, Hafkin J. Phase I Single Ascending Dose and Food Effect Study in Healthy Adults and Phase I/IIa Multiple Ascending Dose Study in Patients with Pulmonary Tuberculosis to Assess Pharmacokinetics, Bactericidal Activity, Tolerability, and Safety of OPC-167832. Antimicrob Agents Chemother 2023; 67:e0147722. [PMID: 37219453 PMCID: PMC10269160 DOI: 10.1128/aac.01477-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 11/04/2022] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
OPC-167832, an inhibitor of decaprenylphosphoryl-β-d-ribose 2'-oxidase, demonstrated potent antituberculosis activity and a favorable safety profile in preclinical studies. This report describes the first two clinical studies of OPC-167832: (i) a phase I single ascending dose (SAD) and food effects study in healthy participants; and (ii) a 14-day phase I/IIa multiple ascending dose (MAD; 3/10/30/90 mg QD) and early bactericidal activity (EBA) trial in participants with drug-susceptible pulmonary tuberculosis (TB). OPC-167832 was well tolerated at single ascending doses (10 to 480 mg) in healthy participants and multiple ascending doses (3 to 90 mg) in participants with TB. In both populations, nearly all treatment-related adverse events were mild and self-limiting, with headache and pruritus being the most common events. Abnormal electrocardiograms results were rare and clinically insignificant. In the MAD study, OPC-167832 plasma exposure increased in a less than dose-proportional manner, with mean accumulation ratios ranging from 1.26 to 1.56 for Cmax and 1.55 to 2.01 for area under the concentration-time curve from 0 to 24 h (AUC0-24h). Mean terminal half-lives ranged from 15.1 to 23.6 h. Pharmacokinetics (PK) characteristics were comparable to healthy participants. In the food effects study, PK exposure increased by less than ~2-fold under fed conditions compared to the fasted state; minimal differences were observed between standard and high-fat meals. Once-daily OPC-167832 showed 14-day bactericidal activity from 3 mg (log10 CFU mean ± standard deviation change from baseline; -1.69 ± 1.15) to 90 mg (-2.08 ± 0.75), while the EBA of Rifafour e-275 was -2.79 ± 0.96. OPC-167832 demonstrated favorable pharmacokinetic and safety profiles, as well as potent EBA in participants with drug-susceptible pulmonary TB.
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Affiliation(s)
- Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Kim Narunsky
- Division of Pulmonology, Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Xiaoyan Zhang
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, Maryland, USA
| | - Yongge Liu
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, Maryland, USA
| | - Jeffrey Hafkin
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, Maryland, USA
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10
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Kurbatova EV, Phillips PPJ, Dorman SE, Sizemore EE, Bryant KE, Purfield AE, Ricaldi J, Brown NE, Johnson JL, Wallis CL, Akol JP, Ocheretina O, Van Hung N, Mayanja-Kizza H, Lourens M, Dawson R, Nhung NV, Pierre S, Musodza Y, Shenje J, Badal-Faesen S, Vilbrun SC, Waja Z, Peddareddy L, Scott NA, Yuan Y, Goldberg SV, Swindells S, Chaisson RE, Nahid P. A Standardized Approach for Collection of Objective Data to Support Outcome Determination for Late-Phase Tuberculosis Clinical Trials. Am J Respir Crit Care Med 2023; 207:1376-1382. [PMID: 36790881 PMCID: PMC10595436 DOI: 10.1164/rccm.202206-1118oc] [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: 06/13/2022] [Accepted: 02/15/2023] [Indexed: 02/16/2023] Open
Abstract
Rationale: We developed a standardized method, possible poor treatment response (PPTR), to help ascertain efficacy endpoints in Study S31/A5349 (NCT02410772), an open-label trial comparing two 4-month rifapentine-based regimens with a standard 6-month regimen for the treatment of pulmonary tuberculosis (TB). Objectives: We describe the use of the PPTR process and evaluate whether the goals of minimizing bias in efficacy endpoint assessment and attainment of relevant data to determine outcomes for all participants were achieved. Methods: A PPTR event was defined as the occurrence of one or more prespecified triggers. Each PPTR required initiation of a standardized evaluation process that included obtaining multiple sputum samples for microbiology. Measurements and Main Results: Among 2,343 participants with culture-confirmed drug-susceptible TB, 454 individuals (19.4%) had a total of 534 individual PPTR events, of which 76.6% were microbiological (positive smear or culture at or after 17 wk). At least one PPTR event was experienced by 92.4% (133 of 144) of participants with TB-related unfavorable outcome and between 13.8% and 14.7% of participants with favorable and not-assessable outcomes. A total of 75% of participants with TB-related unfavorable outcomes had microbiological confirmation of failure to achieve a disease-free cure. Conclusions: Standardized methodologies, such as our PPTR approach, could facilitate unbiased efficacy outcome determinations, improve discrimination between outcomes that are related and unrelated to regimen efficacy, and enhance the ability to conduct pooled analyses of contemporary trials.
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Affiliation(s)
| | - Patrick P. J. Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California
| | - Susan E. Dorman
- Medical University of South Carolina, Charleston, South Carolina
| | - Erin E. Sizemore
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kia E. Bryant
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne E. Purfield
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
- United States Public Health Service Commissioned Corps, Rockville, Maryland
| | - Jessica Ricaldi
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nicole E. Brown
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John L. Johnson
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Uganda–Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Carole L. Wallis
- Lancet Laboratories and Bio Analytical Research Corporation South Africa (BARC SA), Johannesburg, South Africa
| | - Joseph P. Akol
- Uganda–Case Western Reserve University Research Collaboration, Kampala, Uganda
| | | | - Nguyen Van Hung
- Vietnam National Tuberculosis Program/National Lung Hospital, Hanoi, Vietnam
| | | | | | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Nguyen Viet Nhung
- Vietnam National Tuberculosis Program/National Lung Hospital, Hanoi, Vietnam
| | | | - Yeukai Musodza
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - Sharlaa Badal-Faesen
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ziyaad Waja
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Nigel A. Scott
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yan Yuan
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Payam Nahid
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California
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11
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Martinecz A, Boeree MJ, Diacon AH, Dawson R, Hemez C, Aarnoutse RE, Abel Zur Wiesch P. High rifampicin peak plasma concentrations accelerate the slow phase of bacterial decline in tuberculosis patients: Evidence for heteroresistance. PLoS Comput Biol 2023; 19:e1011000. [PMID: 37053266 PMCID: PMC10128972 DOI: 10.1371/journal.pcbi.1011000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 04/25/2023] [Accepted: 03/06/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Antibiotic treatments are often associated with a late slowdown in bacterial killing. This separates the killing of bacteria into at least two distinct phases: a quick phase followed by a slower phase, the latter of which is linked to treatment success. Current mechanistic explanations for the in vitro slowdown are either antibiotic persistence or heteroresistance. Persistence is defined as the switching back and forth between susceptible and non-susceptible states, while heteroresistance is defined as the coexistence of bacteria with heterogeneous susceptibilities. Both are also thought to cause a slowdown in the decline of bacterial populations in patients and therefore complicate and prolong antibiotic treatments. Reduced bacterial death rates over time are also observed within tuberculosis patients, yet the mechanistic reasons for this are unknown and therefore the strategies to mitigate them are also unknown. METHODS AND FINDINGS We analyse a dose ranging trial for rifampicin in tuberculosis patients and show that there is a slowdown in the decline of bacteria. We show that the late phase of bacterial killing depends more on the peak drug concentrations than the total drug exposure. We compare these to pharmacokinetic-pharmacodynamic models of rifampicin heteroresistance and persistence. We find that the observation on the slow phase's dependence on pharmacokinetic measures, specifically peak concentrations are only compatible with models of heteroresistance and incompatible with models of persistence. The quantitative agreement between heteroresistance models and observations is very good ([Formula: see text]). To corroborate the importance of the slowdown, we validate our results by estimating the time to sputum culture conversion and compare the results to a different dose ranging trial. CONCLUSIONS Our findings indicate that higher doses, specifically higher peak concentrations may be used to optimize rifampicin treatments by accelerating bacterial killing in the slow phase. It adds to the growing body of literature supporting higher rifampicin doses for shortening tuberculosis treatments.
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Affiliation(s)
- Antal Martinecz
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Martin J Boeree
- Department of Lung Diseases, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - Andreas H Diacon
- Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- TASK Applied Science, Cape Town, South Africa
| | - Rodney Dawson
- Division of Pulmonology and Department of Medicine, University of Cape Town, Cape Town, South Africa
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - Colin Hemez
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Graduate program in Biophysics, Harvard University, Boston, Massachusetts, United States of America
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Pia Abel Zur Wiesch
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, Pennsylvania, United States of America
- Department of Biology, Eberly College of Science, The Pennsylvania State University, University Park, Pennsylvania, United States of America
- Norwegian Institute of Public Health (Folkehelseinstitutt), Oslo, Norway
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12
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Dooley KE, Hendricks B, Gupte N, Barnes G, Narunsky K, Whitelaw C, Smit T, Ignatius EH, Friedman A, Dorman SE, Dawson R. Assessing Pretomanid for Tuberculosis (APT), a Randomized Phase 2 Trial of Pretomanid-Containing Regimens for Drug-Sensitive Tuberculosis: 12-Week Results. Am J Respir Crit Care Med 2023; 207:929-935. [PMID: 36455068 DOI: 10.1164/rccm.202208-1475oc] [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: 08/04/2022] [Accepted: 11/30/2022] [Indexed: 12/02/2022] Open
Abstract
Rationale: Pretomanid is a new nitroimidazole with proven treatment-shortening efficacy in drug-resistant tuberculosis. Pretomanid-rifamycin-pyrazinamide combinations are potent in mice but have not been tested clinically. Rifampicin, but not rifabutin, reduces pretomanid exposures. Objectives: To evaluate the safety and efficacy of regimens containing pretomanid-rifamycin-pyrazinamide among participants with drug-sensitive pulmonary tuberculosis. Methods: A phase 2, 12-week, open-label randomized trial was conducted of isoniazid and pyrazinamide plus 1) pretomanid and rifampicin (arm 1), 2) pretomanid and rifabutin (arm 2), or 3) rifampicin and ethambutol (standard of care; arm 3). Laboratory values of safety and sputum cultures were collected at Weeks 1, 2, 3, 4, 6, 8, 10, and 12. Time to culture conversion on liquid medium was the primary outcome. Measurements and Main Results: Among 157 participants, 125 (80%) had cavitary disease. Median time to liquid culture negativity in the modified intention-to-treat population (n = 150) was 42 (arm 1), 28 (arm 2), and 56 (arm 3) days (P = 0.01) (adjusted hazard ratio for arm 1 vs. arm 3, 1.41 [95% confidence interval (CI), 0.93-2.12; P = 0.10]; adjusted hazard ratio for arm 2 vs. arm 3, 1.89 [95% CI, 1.24-2.87; P = 0.003]). Eight-week liquid culture conversion was 79%, 89%, and 69%, respectively. Grade ≥3 adverse events occurred in 3 of 56 (5%), 5 of 53 (9%), and 2 of 56 (4%) participants. Six participants were withdrawn because of elevated transaminase concentrations (five in arm 2, one in arm 1). There were three serious adverse events (arm 2) and no deaths. Conclusions: Pretomanid enhanced the microbiologic activity of regimens containing a rifamycin and pyrazinamide. Efficacy and hepatic adverse events appeared highest with the pretomanid and rifabutin-containing regimen. Whether this is due to higher pretomanid concentrations merits exploration. Clinical trial registered with www.clinicaltrials.gov (NCT02256696).
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Affiliation(s)
- Kelly E Dooley
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bronwyn Hendricks
- Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Nikhil Gupte
- Johns Hopkins India Private Limited, Pune, India
| | - Grace Barnes
- School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Kim Narunsky
- Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Colleen Whitelaw
- Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Tanya Smit
- Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Elisa H Ignatius
- School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Adine Friedman
- Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Susan E Dorman
- Medical University of South Carolina, Charleston, South Carolina
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Pettit AC, Phillips PPJ, Kurbatova E, Vernon A, Nahid P, Dawson R, Dooley KE, Sanne I, Waja Z, Mohapi L, Podany AT, Samaneka W, Savic RM, Johnson JL, Muzanyi G, Lalloo UG, Bryant K, Sizemore E, Scott N, Dorman SE, Chaisson RE, Swindells S. Rifapentine With and Without Moxifloxacin for Pulmonary Tuberculosis in People With Human Immunodeficiency Virus (S31/A5349). Clin Infect Dis 2023; 76:e580-e589. [PMID: 36041016 PMCID: PMC10169427 DOI: 10.1093/cid/ciac707] [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: 04/20/2022] [Revised: 08/19/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) Trials Consortium Study 31/AIDS Clinical Trials Group A5349, an international randomized open-label phase 3 noninferiority trial showed that a 4-month daily regimen substituting rifapentine for rifampin and moxifloxacin for ethambutol had noninferior efficacy and was safe for the treatment of drug-susceptible pulmonary TB (DS-PTB) compared with the standard 6-month regimen. We explored results among the prespecified subgroup of people with human immunodeficiency virus (HIV) (PWH). METHODS PWH and CD4+ counts ≥100 cells/μL were eligible if they were receiving or about to initiate efavirenz-based antiretroviral therapy (ART). Primary endpoints of TB disease-free survival 12 months after randomization (efficacy) and ≥ grade 3 adverse events (AEs) on treatment (safety) were compared, using a 6.6% noninferiority margin for efficacy. Randomization was stratified by site, pulmonary cavitation, and HIV status. PWH were enrolled in a staged fashion to support cautious evaluation of drug-drug interactions between rifapentine and efavirenz. RESULTS A total of 2516 participants from 13 countries in sub-Saharan Africa, Asia, and the Americas were enrolled. Among 194 (8%) microbiologically eligible PWH, the median CD4+ count was 344 cells/μL (interquartile range: 223-455). The rifapentine-moxifloxacin regimen was noninferior to control (absolute difference in unfavorable outcomes -7.4%; 95% confidence interval [CI] -20.8% to 6.0%); the rifapentine regimen was not noninferior to control (+7.5% [95% CI, -7.3% to +22.4%]). Fewer AEs were reported in rifapentine-based regimens (15%) than the control regimen (21%). CONCLUSIONS In people with HIV-associated DS-PTB with CD4+ counts ≥100 cells/μL on efavirenz-based ART, the 4-month daily rifapentine-moxifloxacin regimen was noninferior to the 6-month control regimen and was safe. CLINICAL TRIALS REGISTRATION NCT02410772.
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Affiliation(s)
- April C Pettit
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | - Ekaterina Kurbatova
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrew Vernon
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Payam Nahid
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | - Rodney Dawson
- Center for TB Research Innovation, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Kelly E Dooley
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ian Sanne
- Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Waja
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Lerato Mohapi
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthony T Podany
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Wadzanai Samaneka
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Rada M Savic
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | - John L Johnson
- Tuberculosis Research Unit, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Grace Muzanyi
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Umesh G Lalloo
- Enhancing Care Foundation, Durban University of Technology, Durban, South Africa
| | - Kia Bryant
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Erin Sizemore
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nigel Scott
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan E Dorman
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Richard E Chaisson
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Susan Swindells
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Dawson R, Wands DIF, Logan M, Bremner G, Efklides S, Benn L, Henderson P, Grant H, Meredith J, Armstrong K, Wilson DC, Gerasimidis K, Alex G, Russell RK. Comparing Effectiveness of a Generic Oral Nutritional Supplement With Specialized Formula in the Treatment of Active Pediatric Crohn's Disease. Inflamm Bowel Dis 2022; 28:1859-1864. [PMID: 35259266 DOI: 10.1093/ibd/izac039] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is the recommended induction treatment of mild to moderate active pediatric Crohn's disease (CD). This study compared outcomes of 2 proprietary polymeric formulas. Treatment effectiveness was examined along with practical aspects of formula delivery and differences in estimated treatment costs. METHODS Data were retrospectively collected from patients with CD who received a generic oral nutritional supplement (Fortisip) across 2 centers (RCH, Melbourne and RHSC, Edinburgh). This was compared with a prospective cohort (RHC, Glasgow) that used a specialized formula (Modulen IBD). The data collected included patient demographics, remission rates, biochemical markers, administration method, and anthropometrics. The estimated treatment cost was performed by comparing price per kcal between each formula. RESULTS One hundred seventy-one patients were included (106 Fortisip, 65 Modulen IBD, 70 female; median age 13.3 yrs). No difference was demonstrated in remission rate (Fortisip n = 67 of 106 [63%] vs Modulen IBD n = 41 of 64 [64%], P = .89), nonadherence rate (Fortisip n = 7 of 106 [7%] vs Modulen IBD 3 of 64 [5%], P = .57) or method of administration (NGT Fortisip use n = 16 of 106 [12%] vs Modulen IBD 14 of 65 [22%]; P = .31). There was no difference in reduction of biochemical disease markers between the groups (C-reactive protein , P = .13; erythrocyte sedimentation rate, P = .49; fecal calprotectin, P = .94). However, there was a cost-saving of around £500/patient/course if the generic oral nutritional supplement was used. CONCLUSIONS The generic oral nutritional supplement and specialized formulas both had similar clinical effectiveness in induction of remission in pediatric CD. However, there is considerable cost-saving when using a generic oral nutritional supplement.
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Affiliation(s)
- R Dawson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - D I F Wands
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - M Logan
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - G Bremner
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - S Efklides
- Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - L Benn
- Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - P Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
| | - H Grant
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - J Meredith
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - K Armstrong
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - D C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
| | - K Gerasimidis
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - G Alex
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - R K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
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16
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Shahsavar A, Stohler P, Bourenkov G, Zimmermann I, Siegrist M, Guba W, Pinard E, Sinning S, Seeger M, Schneider T, Dawson R, Nissen P. Structural insights into mechanism of glycine reuptake inhibition. Acta Cryst Sect A 2022. [DOI: 10.1107/s2053273322096164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Simms J, Rowbottom C, Dawson R. MO-0545 A quasi-optimal non-coplanar 4π-VMAT solution for treating head & neck cancers. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02379-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Alves-Lima D, Li X, Coulson B, Nesling E, Ludlam G, Degl’Innocenti R, Dawson R, Peruffo M, Lin H. Evaluation of water states in thin proton exchange membrane manufacturing using terahertz time-domain spectroscopy. J Memb Sci 2022. [DOI: 10.1016/j.memsci.2022.120329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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19
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Hsi W, Ricci J, Su Z, Mund K, Dawson R, Indelicato D. The Root-Cause Analysis on Failed Patient-Specific Measurements of Pencil-Beam-Scanning Protons. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Chen RY, Yu X, Smith B, Liu X, Gao J, Diacon AH, Dawson R, Tameris M, Zhu H, Qu Y, Zhang R, Pan S, Jin X, Goldfeder LC, Cai Y, Arora K, Wang J, Vincent J, Malherbe ST, Thienemann F, Wilkinson RJ, Walzl G, Barry CE. Radiological and functional evidence of the bronchial spread of tuberculosis: an observational analysis. Lancet Microbe 2021; 2:e518-e526. [PMID: 34617068 PMCID: PMC8478663 DOI: 10.1016/s2666-5247(21)00058-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct bronchial spread of tuberculosis was extensively described in pre-antibiotic human pathology literature but this description has been overlooked in the post-antibiotic era, in which most pathology data come from animal models that emphasise the granuloma. Modern techniques, such as [18F]2-fluoro-2-deoxy-D-glucose (FDG) PET-CT scans, might provide further insight. Our aim was to understand normal early tuberculosis resolution patterns on pulmonary PET-CT scans in treated patients with tuberculosis who were subsequently cured. METHODS In this observational analysis, we analysed data from PredictTB, an ongoing, prospective, randomised clinical trial that examined sequential baseline and week 4 FDG-PET-CT scans from participants successfully treated (sputum culture negative 18 months after enrolment) for drug-susceptible pulmonary tuberculosis in South Africa and China. Participants who were aged 18-75 years, GeneXpert MTB/RIF positive for tuberculosis and negative for rifampicin resistance, had not yet started tuberculosis treatment, had not been treated for active tuberculosis within the previous 3 years, and met basic safety laboratory criteria were included and participants with diabetes, HIV infection, or with extrapulmonary tuberculosis including pleural tuberculosis were excluded. Scans were assessed by two readers for the location of tuberculosis lesions (eg, cavities and consolidations), bronchial thickening patterns, and changes from baseline to week 4 of treatment. FINDINGS Among the first 124 participants (enrolled from June 22, 2017, to Sept 27, 2018) who were successfully treated, 161 primarily apical cavitary lesions were identified at baseline. Bronchial thickening and inflammation linking non-cavitary consolidative lesions to cavities were observed in 121 (98%) of 124 participants' baseline PET-CT scans. After 4 weeks of treatment, 21 (17%) of 124 participants had new or expanding lesions linked to cavities via bronchial inflammation that were not present at baseline, particularly participants with two or more cavities at baseline and participants from South Africa. INTERPRETATION In participants with pulmonary tuberculosis who were subsequently cured, the location of cavitary and non-cavitary lesions at baseline and new lesions at week 4 of treatment suggest a cavitary origin of disease and bronchial spread through the lungs. Bronchial spread from cavities might play a larger role in the spread of pulmonary tuberculosis than has been appreciated. Elucidating cavity lesion dynamics and Mycobacterium tuberculosis viability within cavities might better explain treatment outcomes and why some patients are cured and others relapse. FUNDING Bill & Melinda Gates Foundation, European and Developing Countries Clinical Trials Partnership, China Ministry of Science and Technology, National Natural Science Foundation of China, and National Institutes of Health. TRANSLATIONS For the Chinese, Afrikaans and Xhosa translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - 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, USA
| | - Bronwyn Smith
- DST-NRF 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, South Africa
| | - Xin Liu
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Jingcai Gao
- Sino-US Tuberculosis Collaborative Research Program, Zhengzhou, Henan, China
| | - Andreas H Diacon
- Department of Medicine, Stellenbosch University, Cape Town, South Africa
- TASK Applied Science, Cape Town, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Michele Tameris
- South African Tuberculosis Vaccine Initiative, University of Cape Town, Cape Town, South Africa
| | - Hong Zhu
- Sino-US Tuberculosis Collaborative Research Program, Zhengzhou, Henan, China
| | - Yahong Qu
- Kaifeng City Institute of Tuberculosis Prevention and Control, Kaifeng, Henan, China
| | - Ruanqing Zhang
- Xinxiang City Institute of Tuberculosis Prevention and Control, Xinxiang, Henan, China
| | - Shouguo Pan
- Zhongmu County Health and Epidemic Prevention Station, Zhongmu, Henan, China
| | - Xiaowei Jin
- Xinmi City Institute of Tuberculosis Prevention and Control, Xinmi, Henan, China
| | - 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, 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, 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, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Joel Vincent
- 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, USA
| | - Stephanus T Malherbe
- DST-NRF 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, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa
- Francis Crick Institute, London, UK
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Gerhard Walzl
- DST-NRF 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, 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, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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21
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Dawson R, Brass R. PO-1759 Pre-treatment CBCT rotations as a predictor of intra-fraction motion in cranial SRS patients. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08210-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Te Brake LHM, de Jager V, Narunsky K, Vanker N, Svensson EM, Phillips PPJ, Gillespie SH, Heinrich N, Hoelscher M, Dawson R, Diacon AH, Aarnoutse RE, Boeree MJ. Increased bactericidal activity but dose-limiting intolerability at 50 mg·kg -1 rifampicin. Eur Respir J 2021; 58:13993003.00955-2020. [PMID: 33542056 PMCID: PMC8411896 DOI: 10.1183/13993003.00955-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 12/07/2020] [Indexed: 01/16/2023]
Abstract
Background Accumulating data indicate that higher rifampicin doses are more effective and shorten tuberculosis (TB) treatment duration. This study evaluated the safety, tolerability, pharmacokinetics, and 7- and 14-day early bactericidal activity (EBA) of increasing doses of rifampicin. Here we report the results of the final cohorts of PanACEA HIGHRIF1, a dose escalation study in treatment-naive adult smear-positive patients with TB. Methods Patients received, in consecutive cohorts, 40 or 50 mg·kg−1 rifampicin once daily in monotherapy (day 1–7), supplemented with standard dose isoniazid, pyrazinamide and ethambutol between days 8 and 14. Results In the 40 mg·kg−1 cohort (n=15), 13 patients experienced a total of 36 adverse events during monotherapy, resulting in one treatment discontinuation. In the 50 mg·kg−1 cohort (n=17), all patients experienced adverse events during monotherapy, 93 in total; 11 patients withdrew or stopped study medication. Adverse events were mostly mild/moderate and tolerability rather than safety related, i.e. gastrointestinal disorders, pruritis, hyperbilirubinaemia and jaundice. There was a more than proportional increase in the rifampicin geometric mean area under the plasma concentration–time curve from time 0 to 12 h (AUC0–24 h) for 50 mg·kg−1 compared with 40 mg·kg−1; 571 (range 320–995) versus 387 (range 201–847) mg·L−1·h, while peak exposures saw proportional increases. Protein-unbound exposure after 50 mg·kg−1 (11% (range 8–17%)) was comparable with lower rifampicin doses. Rifampicin exposures and bilirubin concentrations were correlated (Spearman's ρ=0.670 on day 3, p<0.001). EBA increased considerably with dose, with the highest seen after 50 mg·kg−1: 14-day EBA −0.427 (95% CI −0.500– −0.355) log10CFU·mL−1·day−1. Conclusion Although associated with an increased bactericidal effect, the 50 mg·kg−1 dose was not well tolerated. Rifampicin at 40 mg·kg−1 was well tolerated and therefore selected for evaluation in a phase IIc treatment-shortening trial. While bactericidal activity continues to increase with dose, for the first time we identified dose-limiting intolerability for rifampicin dosed at 50 mg·kg−1; 40 mg·kg−1 seems the optimal tolerable dose for evaluation in TB treatment-shortening trialshttps://bit.ly/37dUIuB
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Affiliation(s)
- Lindsey H M Te Brake
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Kim Narunsky
- UCT Lung Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Elin M Svensson
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Dept of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Stephen H Gillespie
- School of Medicine, Medical and Biological Sciences, University of St Andrews, St Andrews, UK
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research (DZIF), Munich, Germany
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research (DZIF), Munich, Germany
| | - Rodney Dawson
- UCT Lung Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Rob E Aarnoutse
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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23
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Abdelwahab MT, Wasserman S, Brust JCM, Gandhi NR, Meintjes G, Everitt D, Diacon A, Dawson R, Wiesner L, Svensson EM, Maartens G, Denti P. Clofazimine pharmacokinetics in patients with TB: dosing implications. J Antimicrob Chemother 2021; 75:3269-3277. [PMID: 32747933 PMCID: PMC7566350 DOI: 10.1093/jac/dkaa310] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/21/2020] [Indexed: 11/15/2022] Open
Abstract
Background Clofazimine is in widespread use as a key component of drug-resistant TB regimens, but the recommended dose is not evidence based. Pharmacokinetic data from relevant patient populations are needed to inform dose optimization. Objectives To determine clofazimine exposure, evaluate covariate effects on variability, and simulate exposures for different dosing strategies in South African TB patients. Patients and methods Clinical and pharmacokinetic data were obtained from participants with pulmonary TB enrolled in two studies with intensive and sparse sampling for up to 6 months. Plasma concentrations were measured by LC-MS/MS and interpreted with non-linear mixed-effects modelling. Body size descriptors and other potential covariates were tested on pharmacokinetic parameters. We simulated different dosing regimens to safely shorten time to average daily concentration above a putative target concentration of 0.25 mg/L. Results We analysed 1570 clofazimine concentrations from 139 participants; 79 (57%) had drug-resistant TB and 54 (39%) were HIV infected. Clofazimine pharmacokinetics were well characterized by a three-compartment model. Clearance was 11.5 L/h and peripheral volume 10 500 L for a typical participant. Lower plasma exposures were observed in women during the first few months of treatment, explained by higher body fat fraction. Model-based simulations estimated that a loading dose of 200 mg daily for 2 weeks would achieve average daily concentrations above a target efficacy concentration 37 days earlier in a typical TB participant. Conclusions Clofazimine was widely distributed with a long elimination half-life. Disposition was strongly influenced by body fat content, with potential dosing implications for women with TB.
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Affiliation(s)
- Mahmoud Tareq Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - James C M Brust
- Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine, New York, NY, USA
| | - Neel R Gandhi
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine (Infectious Diseases), Emory School of Medicine, Emory University, Atlanta, GA, USA
| | - Graeme Meintjes
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Daniel Everitt
- Global Alliance for TB Drug Development, New York, NY, USA
| | - Andreas Diacon
- Task Applied Science, Bellville, and Department of Medicine, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - Rodney Dawson
- University of Cape Town Lung Institute and Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Tweed CD, Wills GH, Crook AM, Amukoye E, Balanag V, Ban AYL, Bateson ALC, Betteridge MC, Brumskine W, Caoili J, Chaisson RE, Cevik M, Conradie F, Dawson R, Del Parigi A, Diacon A, Everitt DE, Fabiane SM, Hunt R, Ismail AI, Lalloo U, Lombard L, Louw C, Malahleha M, McHugh TD, Mendel CM, Mhimbira F, Moodliar RN, Nduba V, Nunn AJ, Sabi I, Sebe MA, Selepe RAP, Staples S, Swindells S, van Niekerk CH, Variava E, Spigelman M, Gillespie SH. A partially randomised trial of pretomanid, moxifloxacin and pyrazinamide for pulmonary TB. Int J Tuberc Lung Dis 2021; 25:305-314. [PMID: 33762075 PMCID: PMC8009598 DOI: 10.5588/ijtld.20.0513] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND: Treatment for TB is lengthy and toxic, and new regimens are needed.METHODS: Participants with pulmonary drug-susceptible TB (DS-TB) were randomised to receive: 200 mg pretomanid (Pa, PMD) daily, 400 mg moxifloxacin (M) and 1500 mg pyrazinamide (Z) for 6 months (6Pa200MZ) or 4 months (4Pa200MZ); 100 mg pretomanid daily for 4 months in the same combination (4Pa100MZ); or standard DS-TB treatment for 6 months. The primary outcome was treatment failure or relapse at 12 months post-randomisation. The non-inferiority margin for between-group differences was 12.0%. Recruitment was paused following three deaths and not resumed.RESULTS: Respectively 4/47 (8.5%), 11/57 (19.3%), 14/52 (26.9%) and 1/53 (1.9%) DS-TB outcomes were unfavourable in patients on 6Pa200MZ, 4Pa200MZ, 4Pa100MZ and controls. There was a 6.6% (95% CI -2.2% to 15.4%) difference per protocol and 9.9% (95%CI -4.1% to 23.9%) modified intention-to-treat difference in unfavourable responses between the control and 6Pa200MZ arms. Grade 3+ adverse events affected 68/203 (33.5%) receiving experimental regimens, and 19/68 (27.9%) on control. Ten of 203 (4.9%) participants on experimental arms and 2/68 (2.9%) controls died.CONCLUSION: PaMZ regimens did not achieve non-inferiority in this under-powered trial. An ongoing evaluation of PMD remains a priority.
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Affiliation(s)
- C D Tweed
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - G H Wills
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - A M Crook
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - E Amukoye
- Centre for Respiratory Disease Research, Kenya Medical Research Institute (KEMRI), Kenyatta National Hospital, Nairobi, Kenya
| | - V Balanag
- Lung Center of the Philippines, National Centre for Pulmonary Research, Quezon City, The Philippines
| | - A Y L Ban
- Pusat Perubatan Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | | | - M C Betteridge
- Global Alliance for TB Drug Development, New York, NY, USA
| | | | - J Caoili
- Tropical Disease Foundation, Makati Medical Centre, Makati City, Phillippines
| | - R E Chaisson
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Cevik
- Medical School, University of St Andrews, St Andrews, UK
| | - F Conradie
- University of the Witwatersrand, Clinical HIV Research Unit, Johannesburg
| | - R Dawson
- University of Cape Town Lung Institute, Cape Town
| | - A Del Parigi
- Global Alliance for TB Drug Development, New York, NY, USA
| | - A Diacon
- TASK Applied Science, Bellville, South Africa & Division of Physiology, Department of Medical Biochemistry, University of Stellenbosch, Tygerberg, South Africa
| | - D E Everitt
- Global Alliance for TB Drug Development, New York, NY, USA
| | - S M Fabiane
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - R Hunt
- Centre for Clinical Microbiology, UCL, London, UK
| | - A I Ismail
- Universiti Teknologi MARA, Selangor, Malaysia
| | - U Lalloo
- Enhancing Care Foundation, Durban International Clinical Research Site, Wentworth Hospital, Durban
| | - L Lombard
- Global Alliance for TB Drug Development, New York, NY, USA
| | - C Louw
- Madibeng Centre for Research, Brits, & Department of Family Medicine, University of Pretoria, Pretoria
| | - M Malahleha
- Setshaba Research Centre, Soshanguve, South Africa
| | - T D McHugh
- Centre for Clinical Microbiology, UCL, London, UK
| | - C M Mendel
- Global Alliance for TB Drug Development, New York, NY, USA
| | - F Mhimbira
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - R N Moodliar
- THINK (Tuberculosis and HIV Investigative Network), Durban, South Africa
| | | | - A J Nunn
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - I Sabi
- Mbeya Medical Research Center, National Institute for Medical Research, Mbeya, Tanzania
| | - M A Sebe
- The Aurum Institute, Tembisa Clinical Research Centre, Tembisa
| | | | - S Staples
- THINK (Tuberculosis and HIV Investigative Network), Durban, South Africa
| | - S Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - E Variava
- Klerksdorp Tshepong Hospital, Klerksdorp, South Africa
| | - M Spigelman
- Global Alliance for TB Drug Development, New York, NY, USA
| | - S H Gillespie
- Medical School, University of St Andrews, St Andrews, UK
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Malo A, Kellermann T, Ignatius EH, Dooley KE, Dawson R, Joubert A, Norman J, Castel S, Wiesner L. A validated liquid chromatography tandem mass spectrometry assay for the analysis of pretomanid in plasma samples from pulmonary tuberculosis patients. J Pharm Biomed Anal 2021; 195:113885. [PMID: 33406472 PMCID: PMC7868581 DOI: 10.1016/j.jpba.2020.113885] [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: 07/11/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Abstract
A method for the extraction and quantification of pretomanid in 40 μL of human plasma, by high performance liquid chromatography with tandem mass spectrometry (LC-MS/MS) detection was developed and validated. Samples were prepared using liquid-liquid extraction and chromatographic separation was achieved on an Agilent Poroshell C18 column using an isocratic elution at a flow rate of 400 μL/min. Electrospray ionization with mass detection at unit resolution in the multiple reaction monitoring (MRM) mode on an AB Sciex API 3200 mass spectrometer was used. Over the validation period, accuracy, precision, selectivity, sensitivity, recovery and stability were assessed. The calibration range was 10 - 10 000 ng/mL. Inter- and intra-day precision, expressed as the coefficient of variation (%CV), was shown to be lower than 9% at all concentrations tested with accuracies between 95.2 and 110 %. The recovery was 72.4 % overall and reproducible at the low, medium and high end of the calibration range. The method was shown to be specific for pretomanid with no significant matrix effects observed. The validated method facilitated the analysis of pretomanid in plasma collected from adults with pulmonary TB as part of a clinical pharmacokinetic study.
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Affiliation(s)
- Andisiwe Malo
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisa H Ignatius
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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26
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Calligaro GL, de Wit Z, Cirota J, Orrell C, Myers B, Decker S, Stein DJ, Sorsdahl K, Dawson R. Brief psychotherapy administered by non-specialised health workers to address risky substance use in patients with multidrug-resistant tuberculosis: a feasibility and acceptability study. Pilot Feasibility Stud 2021; 7:28. [PMID: 33468251 PMCID: PMC7814702 DOI: 10.1186/s40814-020-00764-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 12/21/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Only 55% of multidrug-resistant tuberculosis (MDR-TB) cases worldwide complete treatment, with problem substance use a risk for default and treatment failure. Nevertheless, there is little research on psychotherapeutic interventions for reducing substance use amongst MDR-TB patients, in general, and on their delivery by non-specialist health workers in particular. OBJECTIVES To explore the feasibility and acceptability of a non-specialist health worker-delivered 4-session brief motivational interviewing and relapse prevention (MI-RP) intervention for problem substance use and to obtain preliminary data on the effects of this intervention on substance use severity, depressive symptoms, psychological distress and functional impairment at 3 months after hospital discharge. METHODS Between December 2015 and October 2016, consenting MDR-TB patients admitted to Brewelskloof Hospital who screened at moderate to severe risk for substance-related problems on the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were enrolled, and a baseline questionnaire administered. In the 4 weeks prior to planned discharge, trained counsellors delivered the MI-RP intervention. The baseline questionnaire was re-administered 3 months post-discharge and qualitative interviews were conducted with a randomly selected sample of participants (n = 10). RESULTS Sixty patients were screened: 40 (66%) met inclusion criteria of which 39 (98%) were enrolled. Of the enrolled patients, 26 (67%) completed the counselling sessions and the final assessment. Qualitative interviews revealed participants' perceptions of the value of the intervention. From baseline to follow-up, patients reported reductions in substance use severity, symptoms of depression, distress and functional impairment. CONCLUSION In this feasibility study, participant retention in the study was moderate. We found preliminary evidence supporting the benefits of the intervention for reducing substance use and symptoms of psychological distress, supported by qualitative reports of patient experiences. Randomised studies are needed to demonstrate efficacy of this intervention before considering potential for wider implementation. TRIAL REGISTRATION South African National Clinical Trials Register ( DOH-27-0315-5007 ) on 01/04/2015 ( http://www.sanctr.gov.za ).
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Affiliation(s)
- Gregory L Calligaro
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Zani de Wit
- Centre for TB Research Innovation, University of Cape Town Lung Institute, George Road, Mowbray, Cape Town, 7925, South Africa
| | - Jacqui Cirota
- Centre for TB Research Innovation, University of Cape Town Lung Institute, George Road, Mowbray, Cape Town, 7925, South Africa
| | - Catherine Orrell
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa
- Addiction Psychiatry Division, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Dan J Stein
- SA MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Rodney Dawson
- Centre for TB Research Innovation, University of Cape Town Lung Institute, George Road, Mowbray, Cape Town, 7925, South Africa.
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa.
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27
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Neilan TG, Nguyen KL, Zaha VG, Chew KW, Morrison L, Ntusi NAB, Toribio M, Awadalla M, Drobni ZD, Nelson MD, Burdo TH, Van Schalkwyk M, Sax PE, Skiest DJ, Tashima K, Landovitz RJ, Daar E, Wurcel AG, Robbins GK, Bolan RK, Fitch KV, Currier JS, Bloomfield GS, Desvigne-Nickens P, Douglas PS, Hoffmann U, Grinspoon SK, Ribaudo H, Dawson R, Goetz MB, Jain MK, Warner A, Szczepaniak LS, Zanni MV. Myocardial Steatosis Among Antiretroviral Therapy-Treated People With Human Immunodeficiency Virus Participating in the REPRIEVE Trial. J Infect Dis 2020; 222:S63-S69. [PMID: 32645158 PMCID: PMC7347082 DOI: 10.1093/infdis/jiaa245] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND People with human immunodeficiency virus (PWH) face increased risks for heart failure and adverse heart failure outcomes. Myocardial steatosis predisposes to diastolic dysfunction, a heart failure precursor. We aimed to characterize myocardial steatosis and associated potential risk factors among a subset of the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) participants. METHODS Eighty-two PWH without known heart failure successfully underwent cardiovascular magnetic resonance spectroscopy, yielding data on intramyocardial triglyceride (IMTG) content (a continuous marker for myocardial steatosis extent). Logistic regression models were applied to investigate associations between select clinical characteristics and odds of increased or markedly increased IMTG content. RESULTS Median (Q1, Q3) IMTG content was 0.59% (0.28%, 1.15%). IMTG content was increased (> 0.5%) among 52% and markedly increased (> 1.5%) among 22% of participants. Parameters associated with increased IMTG content included age (P = .013), body mass index (BMI) ≥ 25 kg/m2 (P = .055), history of intravenous drug use (IVDU) (P = .033), and nadir CD4 count < 350 cells/mm³ (P = .055). Age and BMI ≥ 25 kg/m2 were additionally associated with increased odds of markedly increased IMTG content (P = .049 and P = .046, respectively). CONCLUSIONS A substantial proportion of antiretroviral therapy-treated PWH exhibited myocardial steatosis. Age, BMI ≥ 25 kg/m2, low nadir CD4 count, and history of IVDU emerged as possible risk factors for myocardial steatosis in this group. CLINICAL TRIALS REGISTRATION NCT02344290; NCT03238755.
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Affiliation(s)
- Tomas G Neilan
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kim-Lien Nguyen
- Division of Cardiology, David Geffen School of Medicine at the University of California, Los Angeles and the Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Vlad G Zaha
- Division of Cardiovascular Medicine, Department of Medicine, Advanced Imaging Research Center, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kara W Chew
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Leavitt Morrison
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ntobeko A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Mabel Toribio
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zsofia D Drobni
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael D Nelson
- Applied Physiology and Advanced Imaging Laboratory, Department of Kinesiology, University of Texas at Arlington, Arlington, Texas, USA
| | - Tricia H Burdo
- Department of Neuroscience, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Marije Van Schalkwyk
- Family Clinical Research Unit, Division of Adult Infectious Diseases, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel J Skiest
- Department of Medicine, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts, USA
| | - Karen Tashima
- Division of Infectious Diseases, The Miriam Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Eric Daar
- Lundquist Institute at Harbor–University of California, Los Angeles Medical Center and David Geffen School of Medicine at the University of Los Angeles, Los Angeles, California, USA
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gregory K Robbins
- Division of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert K Bolan
- Los Angeles Lesbian Gay Bisexual Transgender Center, Los Angeles, California, USA
| | - Kathleen V Fitch
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Judith S Currier
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Gerald S Bloomfield
- Duke Clinical Research Institute, Duke Global Health Institute, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Patrice Desvigne-Nickens
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven K Grinspoon
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Heather Ribaudo
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rodney Dawson
- Division of Pulmonology and Department of Medicine, University of Cape Town Lung Institute, Mowbray, Cape Town, South Africa
| | - Matthew Bidwell Goetz
- Infectious Diseases Section, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Mamta K Jain
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alberta Warner
- Division of Cardiology, David Geffen School of Medicine at the University of California, Los Angeles and the Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Lidia S Szczepaniak
- Biomedical Research Consulting in Magnetic Resonance Spectroscopy, Albuquerque, New Mexico, USA
| | - Markella V Zanni
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Correspondence: Markella V. Zanni, MD, Metabolism Unit, Massachusetts General Hospital, 55 Fruit St, 5 LON 207, Boston, MA 02114 ()
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28
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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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29
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Allwood BW, Maasdorp E, Kim GJ, Cooper CB, Goldin J, van Zyl-Smit RN, Bateman ED, Dawson R. Transition from Restrictive to Obstructive Lung Function Impairment During Treatment and Follow-Up of Active Tuberculosis. Int J Chron Obstruct Pulmon Dis 2020; 15:1039-1047. [PMID: 32494129 PMCID: PMC7227812 DOI: 10.2147/copd.s219731] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/10/2020] [Indexed: 11/26/2022] Open
Abstract
Background Pulmonary tuberculosis (PTB) is associated with many forms of chronic lung disease including the development of chronic airflow obstruction (AFO). However, the nature, evolution and mechanisms responsible for the AFO after PTB are poorly understood. The aim of this study was to examine the progression of changes in lung physiology in patients treated for PTB. Methods Immunocompetent, previously healthy, adult patients receiving ambulatory treatment for a first episode of tuberculosis were prospectively followed up with serial lung physiology and quantitative computed tomography (CT) lung scans performed at diagnosis of tuberculosis, 2, 6, 12 and 18 months during and after the completion of treatment. Results Forty-nine patients (median age 26 years; 37.2% males) were included, and 43 were studied. During treatment, lung volumes improved and CT fibrosis scores decreased, but features of AFO and gas trapping emerged, while reduced diffusing capacity (DLco) seen in a majority of patients persisted. Significant increases in total lung capacity (TLC) by plethysmography were seen in the year following treatment completion (median change 5.9% pred., P<0.01) and were driven by large increases in residual volume (RV) (median change +19%pred., P<0.01) but not inspiratory capacity (IC; P=0.41). The change in RV/TLC correlated with significant progression of radiological gas trapping after treatment (P=0.04) but not with emphysema scores. One year after completing treatment, 18.6% of patients had residual restriction (total lung capacity, TLC <80%pred), 16.3% had AFO, 32.6% had gas trapping (RV/TLC>45%), and 78.6% had reduced DLco. Conclusion Simple spirometry alone does not fully reveal the residual respiratory impairments resulting after a first episode of PTB. Changes in physiology evolve after treatment completion, and these findings when taken together, suggest emergence of gas trapping after treatment likely caused by progression of small airway pathology during the healing process.
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Affiliation(s)
- Brian W Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa.,University of Cape Town Lung Institute, and Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elizna Maasdorp
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Grace J Kim
- Center for Computer Visions and Imaging Biomarkers, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Christopher B Cooper
- Departments of Medicine and Physiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jonathan Goldin
- Center for Computer Visions and Imaging Biomarkers, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Richard N van Zyl-Smit
- University of Cape Town Lung Institute, and Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric D Bateman
- University of Cape Town Lung Institute, and Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rodney Dawson
- University of Cape Town Lung Institute, and Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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30
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de Jager VR, Dawson R, van Niekerk C, Hutchings J, Kim J, Vanker N, van der Merwe L, Choi J, Nam K, Diacon AH. Telacebec (Q203), a New Antituberculosis Agent. N Engl J Med 2020; 382:1280-1281. [PMID: 32212527 DOI: 10.1056/nejmc1913327] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
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Suryavanshi N, Murrill M, Gupta A, Hughes M, Hesseling A, Kim S, Naini L, Jones L, Smith B, Gupte N, Dawson R, Mave V, Meshram S, Mendoza-Ticona A, Sanchez J, Kumarasamy N, Comins K, Conradie F, Shenje J, Nerette Fontain S, Garcia-Prats A, Asmelash A, Nedsuwan S, Mohapi L, Lalloo U, Cristina Garcia Ferreira A, Okeyo E, Swindells S, Churchyard G, Shah NS. Willingness to Take Multidrug-resistant Tuberculosis (MDR-TB) Preventive Therapy Among Adult and Adolescent Household Contacts of MDR-TB Index Cases: An International Multisite Cross-sectional Study. Clin Infect Dis 2020; 70:436-445. [PMID: 30919881 PMCID: PMC7188234 DOI: 10.1093/cid/ciz254] [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: 10/16/2018] [Accepted: 03/26/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Household contacts (HHCs) of individuals with multidrug-resistant tuberculosis (MDR-TB) are at high risk of infection and subsequent disease. There is limited evidence on the willingness of MDR-TB HHCs to take MDR-TB preventive therapy (MDR TPT) to decrease their risk of TB disease. METHODS In this cross-sectional study of HHCs of MDR-TB and rifampicin-resistant tuberculosis (RR-TB) index cases from 16 clinical research sites in 8 countries, enrollees were interviewed to assess willingness to take a hypothetical, newly developed MDR TPT if offered. To identify factors associated with willingness to take MDR TPT, a marginal logistic model was fitted using generalized estimating equations to account for household-level clustering. RESULTS From 278 MDR-TB/RR-TB index case households, 743 HHCs were enrolled; the median age of HHCs was 33 (interquartile range, 22-49) years, and 62% were women. HHC willingness to take hypothetical MDR TPT was high (79%) and remained high even with the potential for mild side effects (70%). Increased willingness was significantly associated with current employment or schooling (adjusted odds ratio [aOR], 1.83 [95% confidence interval {CI}, 1.07-3.13]), appropriate TB-related knowledge (aOR, 2.22 [95% CI, 1.23-3.99]), confidence in taking MDR TPT (aOR, 7.16 [95% CI, 3.33-15.42]), and being comfortable telling others about taking MDR TPT (aOR, 2.29 [95% CI, 1.29-4.06]). CONCLUSIONS The high percentage of HHCs of MDR-TB/RR-TB index cases willing to take hypothetical MDR TPT provides important evidence for the potential uptake of effective MDR TPT when implemented. Identified HHC-level variables associated with willingness may inform education and counseling efforts to increase HHC confidence in and uptake of MDR TPT.
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Affiliation(s)
- Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
| | | | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
- Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Anneke Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
| | - Soyeon Kim
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Linda Naini
- Social and Scientific Systems, Inc, Silver Springs, Maryland
| | - Lynne Jones
- Frontier Science and Technology Research Foundation, Amherst, New York
| | - Betsy Smith
- National Institutes of Health, Bethesda, Maryland
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
- Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rodney Dawson
- University of Cape Town Lung Institute, Mowbray, South Africa
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
- Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Sushant Meshram
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
| | | | - Jorge Sanchez
- Asociación Civil Impacta Salud y Educación, San Miguel Clinical Research Site, Lima, Peru
| | | | - Kyla Comins
- TASK Applied Science Clinical Research Site, Bellville
| | | | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - Sandy Nerette Fontain
- GHESKIO Centers–Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | | | | | - Supalert Nedsuwan
- Program for HIV Prevention and Treatment-Chiangrai Prachanukroh Hospital, Thailand
| | - Lerato Mohapi
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg
| | - Umesh Lalloo
- Durban International Clinical Research Site, South Africa
| | | | | | | | - Gavin Churchyard
- Aurum Institute
- School of Public Health, University of the Witwatersrand, Johannesburg
- Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Parktown, South Africa
| | - N Sarita Shah
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Gupta A, Swindells S, Kim S, Hughes MD, Naini L, Wu X, Dawson R, Mave V, Sanchez J, Mendoza A, Gonzales P, Kumarasamy N, Comins K, Conradie F, Shenje J, Fontain SN, Garcia-Prats A, Asmelash A, Nedsuwan S, Mohapi L, Lalloo UG, Ferreira ACG, Mugah C, Harrington M, Jones L, Cox SR, Smith B, Shah NS, Hesseling AC, Churchyard G. Feasibility of Identifying Household Contacts of Rifampin-and Multidrug-resistant Tuberculosis Cases at High Risk of Progression to Tuberculosis Disease. Clin Infect Dis 2020; 70:425-435. [PMID: 30942853 PMCID: PMC7188224 DOI: 10.1093/cid/ciz235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 09/21/2018] [Accepted: 03/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We assessed multidrug-resistant tuberculosis (MDR-TB) cases and their household contacts (HHCs) to inform the development of an interventional clinical trial. METHODS We conducted a cross-sectional study of adult MDR-TB cases and their HHCs in 8 countries with high TB burdens. HHCs underwent symptom screenings, chest radiographies, sputum TB bacteriologies, TB infection (TBI) testing (tuberculin skin test [TST] and interferon gamma release assay [IGRA]), and human immunodeficiency virus (HIV) testing. RESULTS From October 2015 to April 2016, 1016 HHCs from 284 MDR-TB cases were enrolled. At diagnosis, 69% of MDR-TB cases were positive for acid-fast bacilli sputum smears and 43% had cavitary disease; at study entry, 35% remained smear positive after a median MDR-TB treatment duration of 8.8 weeks. There were 9 HHCs that were diagnosed with TB prior to entry and excluded. Of the remaining 1007 HHCs, 41% were male and the median age was 25 years. There were 121 (12%) HHCs that had new cases of TB identified: 17 (2%) were confirmed, 33 (3%) probable, and 71 (7%) possible TB cases. The TBI prevalence (defined as either TST or IGRA positivity) was 72% and varied by age, test used, and country. Of 1007 HHCs, 775 (77%) were considered high-risk per these mutually exclusive groups: 102 (10%) were aged <5 years; 63 (6%) were aged ≥5 and were infected with HIV; and 610 (61%) were aged ≥5 years, were negative for HIV or had an unknown HIV status, and were TBI positive. Only 21 (2%) HHCs were on preventive therapy. CONCLUSIONS The majority of HHCs in these high-burden countries were at high risk of TB disease and infection, yet few were receiving routine preventive therapy. Trials of novel, preventive therapies are urgently needed to inform treatment policy and practice.
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Affiliation(s)
- Amita Gupta
- Johns Hopkins University, Department of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | | | - Soyeon Kim
- Frontier Science & Technology Research Foundation, Amherst, New York
| | - Michael D Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Linda Naini
- Social & Scientific Systems, Silver Spring, Maryland
| | - Xingye Wu
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Rodney Dawson
- University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, South Africa
| | - Vidya Mave
- Johns Hopkins University, Department of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Jorge Sanchez
- Asociación Civil Impacta Salud y Educación, Lima, Peru
| | - Alberto Mendoza
- TASK Applied Science Clinical Research Site, Bellville, South Africa
| | | | | | - Kyla Comins
- TASK Applied Science Clinical Research Site, Bellville
| | - Francesca Conradie
- University of the Witwatersrand Helen Joseph Hospital, Johannesburg, South Africa
| | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - Sandy Nerette Fontain
- GHESKIO Centers Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | - Anthony Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | - Lerato Mohapi
- Soweto Clinical Research Site, University of the Witwatersrand, Johannesburg, South Africa
| | - Umesh G Lalloo
- Durban International Clinical Research Site, Durban University of Technology, South Africa
| | | | | | | | - Lynne Jones
- Frontier Science & Technology Research Foundation, Amherst, New York
| | - Samyra R Cox
- Johns Hopkins University, Department of Medicine, Baltimore, Maryland
| | - Betsy Smith
- National Institutes of Health, Bethesda, Maryland
| | - N Sarita Shah
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Gavin Churchyard
- Aurum Institute, Parktown, South Africa
- University of Witwatersrand, School of Public Health
- Advancing Care and Treatment, South African Medical Research Council, Johannesburg, South Africa
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Tweed CD, Dawson R, Burger DA, Conradie A, Crook AM, Mendel CM, Conradie F, Diacon AH, Ntinginya NE, Everitt DE, Haraka F, Li M, van Niekerk CH, Okwera A, Rassool MS, Reither K, Sebe MA, Staples S, Variava E, Spigelman M. Bedaquiline, moxifloxacin, pretomanid, and pyrazinamide during the first 8 weeks of treatment of patients with drug-susceptible or drug-resistant pulmonary tuberculosis: a multicentre, open-label, partially randomised, phase 2b trial. Lancet Respir Med 2019; 7:1048-1058. [PMID: 31732485 PMCID: PMC7641992 DOI: 10.1016/s2213-2600(19)30366-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 08/28/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND New anti-tuberculosis regimens that are shorter, simpler, and less toxic than those that are currently available are needed as part of the global effort to address the tuberculosis epidemic. We aimed to investigate the bactericidal activity and safety profile of combinations of bedaquiline, pretomanid, moxifloxacin, and pyrazinamide in the first 8 weeks of treatment of pulmonary tuberculosis. METHODS In this multicentre, open-label, partially randomised, phase 2b trial, we prospectively recruited patients with drug-susceptible or rifampicin-resistant pulmonary tuberculosis from seven sites in South Africa, two in Tanzania, and one in Uganda. Patients aged 18 years or older with sputum smear grade 1+ or higher were eligible for enrolment, and a molecular assay (GeneXpert or MTBDRplus) was used to confirm the diagnosis of tuberculosis and to distinguish between drug-susceptible and rifampicin-resistant tuberculosis. Patients who were HIV positive with a baseline CD4 cell count of less than 100 cells per uL were excluded. Patients with drug-susceptible tuberculosis were randomly assigned (1:1:1) using numbered treatment packs with sequential allocation by the pharmacist to receive 56 days of treatment with standard tuberculosis therapy (oral isoniazid, rifampicin, pyrazinamide, and ethambutol; HRZE), or pretomanid (oral 200 mg daily) and pyrazinamide (oral 1500 mg daily) with either oral bedaquiline 400 mg daily on days 1-14 then 200 mg three times per week (BloadPaZ) or oral bedaquiline 200 mg daily (B200PaZ). Patients with rifampicin-resistant tuberculosis received 56 days of the B200PaZ regimen plus moxifloxacin 400 mg daily (BPaMZ). All treatment groups were open label, and randomisation was not stratified. Patients, trial investigators and staff, pharmacists or dispensers, laboratory staff (with the exception of the mycobacteriology laboratory staff), sponsor staff, and applicable contract research organisations were not masked. The primary efficacy outcome was daily percentage change in time to sputum culture positivity (TTP) in liquid medium over days 0-56 in the drug-susceptible tuberculosis population, based on non-linear mixed-effects regression modelling of log10 (TTP) over time. The efficacy analysis population contained patients who received at least one dose of medication and who had efficacy data available and had no major protocol violations. The safety population contained patients who received at least one dose of medication. This study is registered with ClinicalTrials.gov, NCT02193776, and all patients have completed follow-up. FINDINGS Between Oct 24, 2014, and Dec 15, 2015, we enrolled 180 patients with drug-susceptible tuberculosis (59 were randomly assigned to BloadPaZ, 60 to B200PaZ, and 61 to HRZE) and 60 patients with rifampicin-resistant tuberculosis. 57 patients in the BloadPaZ group, 56 in the B200PaZ group, and 59 in the HRZE group were included in the primary analysis. B200PaZ produced the highest daily percentage change in TTP (5·17% [95% Bayesian credibility interval 4·61-5·77]), followed by BloadPaZ (4·87% [4·31-5·47]) and HRZE group (4·04% [3·67-4·42]). The bactericidal activity in B200PaZ and BloadPaZ groups versus that in the HRZE group was significantly different. Higher proportions of patients in the BloadPaZ (six [10%] of 59) and B200PaZ (five [8%] of 60) groups discontinued the study drug than in the HRZE group (two [3%] of 61) because of adverse events. Liver enzyme elevations were the most common grade 3 or 4 adverse events and resulted in the withdrawal of ten patients (five [8%] in the BloadPaZ group, three [5%] in the B200PaZ group, and two [3%] in the HRZE group). Serious treatment-related adverse events affected two (3%) patients in the BloadPaZ group and one (2%) patient in the HRZE group. Seven (4%) patients with drug-susceptible tuberculosis died and four (7%) patients with rifampicin-resistant tuberculosis died. None of the deaths were considered to be related to treatment. INTERPRETATION B200PaZ is a promising regimen to treat patients with drug-susceptible tuberculosis. The bactericidal activity of both these regimens suggests that they have the potential to shorten treatment, and the simplified dosing schedule of B200PaZ could improve treatment adherence in the field. However, these findings must be investigated further in a phase 3 trial assessing treatment outcomes. FUNDING TB Alliance, UK Department for International Development, Bill & Melinda Gates Foundation, US Agency for International Development, Directorate General for International Cooperation of the Netherlands, Irish Aid, Australia Department of Foreign Affairs and Trade, and the Federal Ministry for Education and Research of Germany.
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Affiliation(s)
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa,Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Divan A Burger
- Department of Statistics, University of Pretoria, Pretoria, South Africa
| | | | | | - Carl M Mendel
- Global Alliance for TB Drug Development, New York, NY, USA
| | - Francesca Conradie
- Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Andreas H Diacon
- TASK Applied Science, Bellville, South Africa,Division of Physiology, Department of Medical Biochemistry, Stellenbosch University, Tygerberg, South Africa
| | | | | | - Frederick Haraka
- Ifakara Health Institute Bagamoyo Research and Training Center, Bagamoyo, Tanzania
| | - Mengchun Li
- Global Alliance for TB Drug Development, New York, NY, USA
| | | | - Alphonse Okwera
- Uganda Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
| | - Klaus Reither
- Ifakara Health Institute Bagamoyo Research and Training Center, Bagamoyo, Tanzania,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Ebrahim Variava
- MDR Unit, Klerksdorp Tshepong Hospital, Klerksdorp, South Africa
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Svensson EM, Svensson RJ, Te Brake LHM, Boeree MJ, Heinrich N, Konsten S, Churchyard G, Dawson R, Diacon AH, Kibiki GS, Minja LT, Ntingiya NE, Sanne I, Gillespie SH, Hoelscher M, Phillips PPJ, Simonsson USH, Aarnoutse R. The Potential for Treatment Shortening With Higher Rifampicin Doses: Relating Drug Exposure to Treatment Response in Patients With Pulmonary Tuberculosis. Clin Infect Dis 2019; 67:34-41. [PMID: 29917079 PMCID: PMC6005123 DOI: 10.1093/cid/ciy026] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/10/2018] [Indexed: 12/27/2022] Open
Abstract
Background Tuberculosis remains a huge public health problem and the prolonged treatment duration obstructs effective tuberculosis control. Higher rifampicin doses have been associated with better bactericidal activity, but optimal dosing is uncertain. This analysis aimed to characterize the relationship between rifampicin plasma exposure and treatment response over 6 months in a recent study investigating the potential for treatment shortening with high-dose rifampicin. Methods Data were analyzed from 336 patients with pulmonary tuberculosis (97 with pharmacokinetic data) treated with rifampicin doses of 10, 20, or 35 mg/kg. The response measure was time to stable sputum culture conversion (TSCC). We derived individual exposure metrics with a previously developed population pharmacokinetic model of rifampicin. TSCC was modeled using a parametric time-to-event approach, and a sequential exposure-response analysis was performed. Results Higher rifampicin exposures increased the probability of early culture conversion. No maximal limit of the effect was detected within the observed range. The expected proportion of patients with stable culture conversion on liquid medium at week 8 was predicted to increase from 39% (95% confidence interval, 37%-41%) to 55% (49%-61%), with the rifampicin area under the curve increasing from 20 to 175 mg/L·h (representative for 10 and 35 mg/kg, respectively). Other predictors of TSCC were baseline bacterial load, proportion of culture results unavailable, and substitution of ethambutol for either moxifloxacin or SQ109. Conclusions Increasing rifampicin exposure shortened TSCC, and the effect did not plateau, indicating that doses >35 mg/kg could be yet more effective. Optimizing rifampicin dosage while preventing toxicity is a clinical priority.
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Affiliation(s)
- Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin J Boeree
- Department of Lung Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Norbert Heinrich
- Medical Centre of the University of Munich (LMU), Munich Partner Site, Germany.,German Center for Infection Research (DZIF), Munich Partner Site, Germany
| | - Sarah Konsten
- Medical Centre of the University of Munich (LMU), Munich Partner Site, Germany.,German Center for Infection Research (DZIF), Munich Partner Site, Germany
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersr, Johannesburg, South Africa.,Advancing Treatment and Care for TB and HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | | | | | - Ian Sanne
- University of the Witswatersrand, Johannesburg, South Africa
| | | | - Michael Hoelscher
- Medical Centre of the University of Munich (LMU), Munich Partner Site, Germany.,German Center for Infection Research (DZIF), Munich Partner Site, Germany
| | - Patrick P J Phillips
- MRC Clinical Trials Unit, University College of London, United Kingdom.,Division of Pulmonary and Critical Care Medicine, University of California San Francisco, US
| | | | - Rob Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Allwood B, Maasdorp E, Kim G, Cooper C, Goldin J, Van Zyl-Smit R, Bateman E, Dawson R. Transition from restrictive to obstructive lung function impairment during treatment and follow-up of active pulmonary tuberculosis. Tuberculosis (Edinb) 2019. [DOI: 10.1183/13993003.congress-2019.pa2948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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36
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Opollo VS, Wu X, Hughes MD, Swindells S, Gupta A, Hesseling A, Churchyard G, Kim S, Lando R, Dawson R, Mave V, Mendoza A, Gonzales P, Kumarasamy N, von Groote-Bidlingmaier F, Conradie F, Shenje J, Fontain SN, Garcia-Prats A, Asmelash A, Nedsuwan S, Mohapi L, Mngqibisa R, Garcia Ferreira AC, Okeyo E, Naini L, Jones L, Smith B, Shah NS. HIV testing uptake among the household contacts of multidrug-resistant tuberculosis index cases in eight countries. Int J Tuberc Lung Dis 2019; 22:1443-1449. [PMID: 30606316 DOI: 10.5588/ijtld.18.0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING The household contacts (HHCs) of multidrug-resistant tuberculosis (MDR-TB) index cases are at high risk of tuberculous infection and disease progression, particularly if infected with the human immunodeficiency virus (HIV). HIV testing is important for risk assessment and clinical management. METHODS This was a cross-sectional, multi-country study of adult MDR-TB index cases and HHCs. All adult and child HHCs were offered HIV testing if never tested or if HIV-negative >1 year previously when last tested. We measured HIV testing uptake and used logistic regression to evaluate predictors. RESULTS A total of 1007 HHCs of 284 index cases were enrolled in eight countries. HIV status was known at enrolment for 226 (22%) HHCs; 39 (4%) were HIV-positive. HIV testing was offered to 769 (98%) of the 781 remaining HHCs; 544 (71%) agreed to testing. Of 535 who were actually tested, 26 (5%) were HIV-infected. HIV testing uptake varied by site (median 86%, range 0-100%; P < 0.0001), and was lower in children aged <18 years than in adults (59% vs. 78%; adjusted for site P < 0.0001). CONCLUSIONS HIV testing of HHCs of MDR-TB index cases is feasible and high-yield, with 5% testing positive. Reasons for low test uptake among children and at specific sites-including sites with high HIV prevalence-require further study to ensure all persons at risk for HIV are aware of their status.
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Affiliation(s)
- V S Opollo
- Kenya Medical Research Institute, Kisumu, Kenya
| | - X Wu
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - M D Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - S Swindells
- University of Nebraska Medical Center, Omaha, Nebraska
| | - A Gupta
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - A Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg
| | | | - S Kim
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, Frontier Science & Technology Research Foundation, Amherst, New York, USA
| | - R Lando
- Kenya Medical Research Institute, Kisumu, Kenya
| | - R Dawson
- University of Cape Town Lung Institute, Mowbray, South Africa
| | - V Mave
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
| | - A Mendoza
- Asociacion Civil Impacta Salud y Educacion, Barranco Clinical Research Site, Lima
| | - P Gonzales
- Asociación Civil Impacta Salud y Educación, San Miguel Clinical Research Site (CRS), Lima, Peru
| | - N Kumarasamy
- Chennai Antiviral Research and Treatment CRS, Chennai, India
| | | | - F Conradie
- University of the Witwatersrand, Helen Joseph Hospital, Johannesburg
| | - J Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - S N Fontain
- GHESKIO (Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes) Centers Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg
| | | | - S Nedsuwan
- Prevention and Treatment of HIV infection, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | | | - R Mngqibisa
- Durban International CRS, Durban, South Africa
| | | | - E Okeyo
- Kenya Medical Research Institute, Kisumu, Kenya
| | - L Naini
- Social & Scientific Systems, Inc, Silver Springs, Maryland
| | - L Jones
- Frontier Science & Technology Research Foundation, Amherst, New York, USA
| | - B Smith
- National Institutes of Health, Bethesda, Maryland
| | - N S Shah
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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37
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Tweed CD, Crook AM, Dawson R, Diacon AH, McHugh TD, Mendel CM, Meredith SK, Mohapi L, Murphy ME, Nunn AJ, Phillips PPJ, Singh KP, Spigelman M, Gillespie SH. Toxicity related to standard TB therapy for pulmonary tuberculosis and treatment outcomes in the REMoxTB study according to HIV status. BMC Pulm Med 2019; 19:152. [PMID: 31412895 PMCID: PMC6694514 DOI: 10.1186/s12890-019-0907-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The phase III REMoxTB study prospectively enrolled HIV-positive (with CD4+ count > 250 cells, not on anti-retroviral therapy) and HIV-negative patients. We investigated the incidence of adverse events and cure rates according to HIV status for patients receiving standard TB therapy in the trial. METHODS Forty-two HIV-positive cases were matched to 220 HIV-negative controls by age, gender, ethnicity, and trial site using coarsened exact matching. Grade 3 and 4 adverse events (AEs) were summarised by MedDRA System Organ Class. Kaplan-Meier curves for time to first grade 3 or 4 AE were constructed according to HIV status with hazard ratios calculated. Patients were considered cured if they were culture negative 18 months after commencing therapy with ≥2 consecutive negative culture results. RESULTS Twenty of 42 (47.6%) HIV-positive and 34 of 220 (15.5%) HIV-negative patients experienced ≥1 grade 3 or 4 AE, respectively. The majority of these were hepatobiliary disorders that accounted for 12 of 40 (30.0%) events occurring in 6 of 42 (14.3%) HIV-positive patients and for 15 of 60 (25.0%) events occurring in 9 of 220 (4.1%) HIV-negative patients. The median time to first grade 3 or 4 AE was 54 days (IQR 15.5-59.0) for HIV-positive and 29.5 days (IQR 9.0-119.0) for HIV-negative patients, respectively. The hazard ratio for experiencing a grade 3 or 4 AE among HIV-positive patients was 3.25 (95% CI 1.87-5.66, p < 0.01). Cure rates were similar, with 38 of 42 (90.5%) HIV-positive and 195 of 220 (88.6%) HIV-negative patients (p = 0.73) cured at 18 months. CONCLUSIONS HIV-positive patients receiving standard TB therapy in the REMoxTB study were at greater risk of adverse events during treatment but cure rates were similar when compared to a matched sample of HIV-negative patients.
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Affiliation(s)
- Conor D Tweed
- MRC Clinical Trials Unit at University College London, London, UK.
| | - Angela M Crook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Timothy D McHugh
- Division of Infection and Immunity, University College London, London, UK
| | | | - Sarah K Meredith
- MRC Clinical Trials Unit at University College London, London, UK
| | - Lerato Mohapi
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Michael E Murphy
- Division of Infection and Immunity, University College London, London, UK
| | - Andrew J Nunn
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Kasha P Singh
- The Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Parkville, Australia
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Swindells S, Gupta A, Kim S, Hughes MD, Sanchez J, Mave V, Dawson R, Kumarasamy N, Comins K, Smith B, Rustomjee R, Naini L, Shah NS, Hesseling A, Churchyard G. Resource utilization for multidrug-resistant tuberculosis household contact investigations (A5300/I2003). Int J Tuberc Lung Dis 2018; 22:1016-1022. [PMID: 30092866 DOI: 10.5588/ijtld.18.0163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines recommend evaluation of the household contacts (HHCs) of individuals with multidrug-resistant tuberculosis (MDR-TB); however, implementation of this policy is challenging. OBJECTIVE To describe the resource utilization and operational challenges encountered when identifying and characterizing adult MDR-TB index cases and their HHCs. DESIGN Cross-sectional study of adult MDR-TB index cases and HHCs at 16 clinical research sites in eight countries. Site-level resource utilization was assessed with surveys. RESULTS Between October 2015 and April 2016, 308 index cases and 1018 HHCs were enrolled. Of 280 index cases with sputum collected, 94 were smear-positive (34%, 95%CI 28-39), and of 201 with chest X-rays, 87 had cavitary disease (43%, 95%CI 37-50) after a mean duration of treatment of 8 weeks. Staff required 512 attempts to evaluate the 308 households, with a median time per attempt of 4 h; 77% (95%CI 73-80) of HHCs were at increased risk for TB: 13% were aged <5 years, 8% were infected with the human immunodeficiency virus, and 79% were positive on the tuberculin skin test/interferon-gamma release assay. One hundred and twenty-one previously undiagnosed TB cases were identified. Issues identified by site staff included the complexity of personnel and participant transportation, infection control, personnel safety and management of stigma. CONCLUSION HHC investigations can be high yield, but are labor-intensive.
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Affiliation(s)
- S Swindells
- University of Nebraska Medical Center, Omaha, Nebraska
| | - A Gupta
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - S Kim
- Frontier Science Foundation, Brookline, Massachusetts
| | - M D Hughes
- Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - J Sanchez
- Asociación Civil Impacta Salud y Educación, Lima, Peru
| | - V Mave
- Byramjee Jeejeebhoy Government Medical College Clinical Research Site, Pune, India
| | - R Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - N Kumarasamy
- Chennai Antiviral Research and Treatment CRS, Chennai, India
| | - K Comins
- Task Applied Science CRS, Bellville, South Africa
| | - B Smith
- National Institutes of Health, Bethesda, MD, USA
| | - R Rustomjee
- National Institutes of Health, Bethesda, MD, USA
| | - L Naini
- Social & Scientific Systems, Inc, Silver Springs, Maryland
| | - N S Shah
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - A Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg
| | - G Churchyard
- The Aurum Institute, Johannesburg, School of Public Health, University of Witwatersrand, Johannesburg, Advancing Care and Treatment for TB and HIV, South African Medical Research Council, Johannesburg, South Africa
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Dawson R, Walace S, Coe B, Bonvento B, Owen A, Lynch J, McGrath B. Better tracheostomy care through targeted education using social media. Br J Anaesth 2018. [DOI: 10.1016/j.bja.2018.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Tweed CD, Crook AM, Amukoye EI, Dawson R, Diacon AH, Hanekom M, McHugh TD, Mendel CM, Meredith SK, Murphy ME, Murthy SE, Nunn AJ, Phillips PPJ, Singh KP, Spigelman M, Wills GH, Gillespie SH. Toxicity associated with tuberculosis chemotherapy in the REMoxTB study. BMC Infect Dis 2018; 18:317. [PMID: 29996783 PMCID: PMC6042413 DOI: 10.1186/s12879-018-3230-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The incidence and severity of tuberculosis chemotherapy toxicity is poorly characterised. We used data available from patients in the REMoxTB trial to provide an assessment of the risks associated with the standard regimen and two experimental regimens containing moxifloxacin. METHODS All grade 3 & 4 adverse events (AEs) and their relationship to treatment for patients who had taken at least one dose of therapy in the REMoxTB clinical trial were recorded. Univariable logistic regression was used to test the relationship of baseline characteristics to the incidence of grade 3 & 4 AEs and significant characteristics (p < 0.10) were incorporated into a multivariable model. The timing of AEs during therapy was analysed in standard therapy and the experimental arms. Logistic regression was used to investigate the relationship between AEs (total and related-only) and microbiological cure on treatment. RESULTS In the standard therapy arm 57 (8.9%) of 639 patients experienced ≥1 related AEs with 80 of the total 113 related events (70.8%) occurring in the intensive phase of treatment. Both four-month experimental arms ("isoniazid arm" with moxifloxacin substituted for ethambutol & "ethambutol arm" with moxifloxacin substituted for isoniazid) had a lower total of related grade 3 & 4 AEs than standard therapy (63 & 65 vs 113 AEs). Female gender (adjOR 1.97, 95% CI 0.91-1.83) and HIV-positive status (adjOR 3.33, 95% CI 1.55-7.14) were significantly associated with experiencing ≥1 related AE (p < 0.05) on standard therapy. The most common adverse events on standard therapy related to hepatobiliary, musculoskeletal and metabolic disorders. Patients who experienced ≥1 related AE were more likely to fail treatment or relapse (adjOR 3.11, 95% CI 1.59-6.10, p < 0.001). CONCLUSIONS Most AEs considered related to standard therapy occurred in the intensive phase of treatment with female patients and HIV-positive patients demonstrating a significantly higher risk of AEs during treatment. Almost a tenth of standard therapy patients had a significant side effect, whereas both experimental arms recorded a lower incidence of toxicity. That patients with one or more AE are more likely to fail treatment suggests that treatment outcomes could be improved by identifying such patients through targeted monitoring.
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Affiliation(s)
- Conor D. Tweed
- MRC Clinical Trials Unit at University College London, London, UK
| | - Angela M. Crook
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Timothy D. McHugh
- Division of Infection and Immunity, University College London, London, UK
| | | | | | - Michael E. Murphy
- Division of Infection and Immunity, University College London, London, UK
| | | | - Andrew J. Nunn
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Kasha P. Singh
- The Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
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Murthy SE, Chatterjee F, Crook A, Dawson R, Mendel C, Murphy ME, Murray SR, Nunn AJ, Phillips PPJ, Singh KP, McHugh TD, Gillespie SH. Pretreatment chest x-ray severity and its relation to bacterial burden in smear positive pulmonary tuberculosis. BMC Med 2018; 16:73. [PMID: 29779492 PMCID: PMC5961483 DOI: 10.1186/s12916-018-1053-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 04/09/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chest radiographs are used for diagnosis and severity assessment in tuberculosis (TB). The extent of disease as determined by smear grade and cavitation as a binary measure can predict 2-month smear results, but little has been done to determine whether radiological severity reflects the bacterial burden at diagnosis. METHODS Pre-treatment chest x-rays from 1837 participants with smear-positive pulmonary TB enrolled into the REMoxTB trial (Gillespie et al., N Engl J Med 371:1577-87, 2014) were retrospectively reviewed. Two clinicians blinded to clinical details using the Ralph scoring system performed separate readings. An independent reader reviewed discrepant results for quality assessment and cavity presence. Cavitation presence was plotted against time to positivity (TTP) of sputum liquid cultures (MGIT 960). The Wilcoxon rank sum test was performed to calculate the difference in average TTP for these groups. The average lung field affected was compared to log 10 TTP by linear regression. Baseline markers of disease severity and patient characteristics were added in univariable regression analysis against radiological severity and a multivariable regression model was created to explore their relationship. RESULTS For 1354 participants, the median TTP was 117 h (4.88 days), being 26 h longer (95% CI 16-30, p < 0.001) in patients without cavitation compared to those with cavitation. The median percentage of lung-field affected was 18.1% (IQR 11.3-28.8%). For every 10-fold increase in TTP, the area of lung field affected decreased by 11.4%. Multivariable models showed that serum albumin decreased significantly as the percentage of lung field area increased in both those with and without cavitation. In addition, BMI and logged TTP had a small but significant effect in those with cavitation and the number of severe TB symptoms in the non-cavitation group also had a small effect, whilst other factors found to be significant on univariable analysis lost this effect in the model. CONCLUSIONS The radiological severity of disease on chest x-ray prior to treatment in smear positive pulmonary TB patients is weakly associated with the bacterial burden. When compared against other variables at diagnosis, this effect is lost in those without cavitation. Radiological severity does reflect the overall disease severity in smear positive pulmonary TB, but we suggest that clinicians should be cautious in over-interpreting the significance of radiological disease extent at diagnosis.
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Affiliation(s)
- S E Murthy
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - F Chatterjee
- Department of Radiology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London, E1 1BB, UK
| | - A Crook
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - R Dawson
- University of Cape Town Lung Institute, George Street, Mowbray, Cape Town, South Africa
| | - C Mendel
- Global Alliance for Tuberculosis Drug Development, New York, NY, 10005, USA
| | - M E Murphy
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - S R Murray
- Global Alliance for Tuberculosis Drug Development, New York, NY, 10005, USA
| | - A J Nunn
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - P P J Phillips
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Kasha P Singh
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - T D McHugh
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - S H Gillespie
- Medical and Biological Sciences, School of Medicine, University of St Andrews, North Haugh, St Andrews, KY16 9TF, UK.
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Svensson RJ, Svensson EM, Aarnoutse RE, Diacon AH, Dawson R, Gillespie SH, Moodley M, Boeree MJ, Simonsson USH. Greater Early Bactericidal Activity at Higher Rifampicin Doses Revealed by Modeling and Clinical Trial Simulations. J Infect Dis 2018; 218:991-999. [DOI: 10.1093/infdis/jiy242] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/24/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Elin M Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Sweden
- Department of Pharmacy, Radboud Institute for Health Sciences, Nijmegen
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Nijmegen
| | | | - 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
| | | | | | - Martin J Boeree
- Department of Lung Diseases, Radboud University Medical Center, Nijmegen
- University Center for Chronic Diseases Dekkerswald, Groesbeek, the Netherlands
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Tweed CD, Wills GH, Crook AM, Dawson R, Diacon AH, Louw CE, McHugh TD, Mendel C, Meredith S, Mohapi L, Murphy ME, Murray S, Murthy S, Nunn AJ, Phillips PPJ, Singh K, Spigelman M, Gillespie SH. Liver toxicity associated with tuberculosis chemotherapy in the REMoxTB study. BMC Med 2018; 16:46. [PMID: 29592805 PMCID: PMC5875008 DOI: 10.1186/s12916-018-1033-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/07/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Drug-induced liver injury (DILI) is a common complication of tuberculosis treatment. We utilised data from the REMoxTB clinical trial to describe the incidence of predisposing factors and the natural history in patients with liver enzyme levels elevated in response to tuberculosis treatment. METHODS Patients received either standard tuberculosis treatment (2EHRZ/4HR), or a 4-month regimen in which moxifloxacin replaced either ethambutol (isoniazid arm, 2MHRZ/2MHR) or isoniazid (ethambutol arm, 2EMRZ/2MR). Hepatic enzymes were measured at 0, 2, 4, 8, 12 and 17 weeks and as clinically indicated during reported adverse events. Patients included were those receiving at least one dose of drug and with two or more hepatic enzyme measurements. RESULTS A total of 1928 patients were included (639 2EHRZ/4HR, 654 2MHRZ/2MHR and 635 2EMRZ/2MR). DILI was defined as peak alanine aminotransferase (ALT) ≥ 5 times the upper limit of normal (5 × ULN) or ALT ≥ 3 × ULN with total bilirubin > 2 × ULN. DILI was identified in 58 of the 1928 (3.0%) patients at a median time of 28 days (interquartile range IQR 14-56). Of 639 (6.4%) patients taking standard tuberculosis therapy, 41 experienced clinically significant enzyme elevations (peak ALT ≥ 3 × ULN). On standard therapy, 21.1% of patients aged >55 years developed a peak ALT/aspartate aminotransferase (AST) ≥ 3 × ULN (p = 0.01) and 15% of HIV-positive patients experienced a peak ALT/AST ≥ 3 × ULN compared to 9% of HIV-negative patients (p = 0.160). The median peak ALT/AST was higher in isoniazid-containing regimens vs no-isoniazid regimens (p < 0.05), and lower in moxifloxacin-containing arms vs no-moxifloxacin arms (p < 0.05). Patients receiving isoniazid reached a peak ALT ≥ 3 × ULN 9.5 days earlier than those on the ethambutol arm (median time of 28 days vs 18.5 days). Of the 67 Asian patients with a peak ALT/AST ≥ 3 × ULN, 57 (85.1%) were on an isoniazid-containing regimen (p = 0.008). CONCLUSIONS Our results provide evidence of the risk of DILI in tuberculosis patients on standard treatment. Older patients on standard therapy, HIV-positive patients, Asian patients and those receiving isoniazid were at higher risk of elevated enzyme levels. Monitoring hepatic enzymes during the first 2 months of standard therapy detected approximately 75% of patients with a peak enzyme elevation ≥3 × ULN, suggesting this should be a standard of care. These results provide evidence for the potential of moxifloxacin in hepatic sparing.
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Affiliation(s)
| | | | - Angela M Crook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Timothy D McHugh
- Division of Infection and Immunity, University College London, London, UK
| | | | - Sarah Meredith
- MRC Clinical Trials Unit at University College London, London, UK
| | - Lerato Mohapi
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Michael E Murphy
- Division of Infection and Immunity, University College London, London, UK
| | | | - Sara Murthy
- Division of Infection and Immunity, University College London, London, UK
| | - Andrew J Nunn
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Kasha Singh
- The Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | | | - S H Gillespie
- University of St Andrews Medical School, St Andrews, UK
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Chen RY, Via LE, Dodd LE, Walzl G, Malherbe ST, Loxton AG, Dawson R, Wilkinson RJ, Thienemann F, Tameris M, Hatherill M, Diacon AH, Liu X, Xing J, Jin X, Ma Z, Pan S, Zhang G, Gao Q, Jiang Q, Zhu H, Liang L, Duan H, Song T, Alland D, Tartakovsky M, Rosenthal A, Whalen C, Duvenhage M, Cai Y, Goldfeder LC, Arora K, Smith B, Winter J, Barry Iii CE. Using biomarkers to predict TB treatment duration (Predict TB): a prospective, randomized, noninferiority, treatment shortening clinical trial. Gates Open Res 2017. [PMID: 29528048 PMCID: PMC5841574 DOI: 10.12688/gatesopenres.12750.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: By the early 1980s, tuberculosis treatment was shortened from 24 to 6 months, maintaining relapse rates of 1-2%. Subsequent trials attempting shorter durations have failed, with 4-month arms consistently having relapse rates of 15-20%. One trial shortened treatment only among those without baseline cavity on chest x-ray and whose month 2 sputum culture converted to negative. The 4-month arm relapse rate decreased to 7% but was still significantly worse than the 6-month arm (1.6%, P<0.01). We hypothesize that PET/CT characteristics at baseline, PET/CT changes at one month, and markers of residual bacterial load will identify patients with tuberculosis who can be cured with 4 months (16 weeks) of standard treatment. Methods: This is a prospective, multicenter, randomized, phase 2b, noninferiority clinical trial of pulmonary tuberculosis participants. Those eligible start standard of care treatment. PET/CT scans are done at weeks 0, 4, and 16 or 24. Participants who do not meet early treatment completion criteria (baseline radiologic severity, radiologic response at one month, and GeneXpert-detectable bacilli at four months) are placed in Arm A (24 weeks of standard therapy). Those who meet the early treatment completion criteria are randomized at week 16 to continue treatment to week 24 (Arm B) or complete treatment at week 16 (Arm C). The primary endpoint compares the treatment success rate at 18 months between Arms B and C. Discussion: Multiple biomarkers have been assessed to predict TB treatment outcomes. This study uses PET/CT scans and GeneXpert (Xpert) cycle threshold to risk stratify participants. PET/CT scans are not applicable to global public health but could be used in clinical trials to stratify participants and possibly become a surrogate endpoint. If the Predict TB trial is successful, other immunological biomarkers or transcriptional signatures that correlate with treatment outcome may be identified. Trial Registration: NCT02821832
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Affiliation(s)
- Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Laura E Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA.,Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - Lori E Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Gerhard Walzl
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanus T Malherbe
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - André G Loxton
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University Of Cape Town Lung Institute, University of Cape Town (UCT), Cape Town, South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa.,Francis Crick Institute, London, NW1 2AT, UK.,Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Friedrich Thienemann
- Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa.,Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Michele Tameris
- South African Tuberculosis Vaccine Initiative, University of Cape Town (UCT), Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, University of Cape Town (UCT), Cape Town, South Africa
| | - Andreas H Diacon
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
| | - Xin Liu
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Jin Xing
- Henan Provincial Institute of Tuberculosis and Prevention, Henan Center for Disease Control, Zhengzhou, Henan, China
| | - Xiaowei Jin
- Xinmi City Institute of Tuberculosis Prevention and Control, Xinmi, Henan, China
| | - Zhenya Ma
- Kaifeng City Institute of Tuberculosis Prevention and Control, Kaifeng, Henan, China
| | - Shouguo Pan
- Zhongmu County Health and Epidemic Prevention Station, Zhongmu, Henan, China
| | - Guolong Zhang
- Henan Provincial Institute of Tuberculosis and Prevention, Henan Center for Disease Control, Zhengzhou, Henan, China
| | - Qian Gao
- Fudan University, Shanghai, China
| | - Qi Jiang
- Fudan University, Shanghai, China
| | - Hong Zhu
- Sino-US Tuberculosis Collaborative Research Program, Zhengzhou, Henan, China
| | - Lili Liang
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
| | | | - Taeksun Song
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - David Alland
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Michael Tartakovsky
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Alex Rosenthal
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Christopher Whalen
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Michael Duvenhage
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lisa C Goldfeder
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Kriti Arora
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Bronwyn Smith
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jill Winter
- Catalysis Foundation for Health, Emeryville, CA, USA
| | - Clifton E Barry Iii
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA.,Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa
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Svensson RJ, Aarnoutse RE, Diacon AH, Dawson R, Gillespie SH, Boeree MJ, Simonsson USH. A Population Pharmacokinetic Model Incorporating Saturable Pharmacokinetics and Autoinduction for High Rifampicin Doses. Clin Pharmacol Ther 2017; 103:674-683. [PMID: 28653479 PMCID: PMC5888114 DOI: 10.1002/cpt.778] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/09/2017] [Accepted: 06/16/2017] [Indexed: 02/04/2023]
Abstract
Accumulating evidence suggests that increasing doses of rifampicin may shorten tuberculosis treatment. The PanACEA HIGHRIF1 trial assessed safety, pharmacokinetics, and antimycobacterial activity of rifampicin at doses up to 40 mg/kg. Eighty-three pulmonary tuberculosis patients received 10, 20, 25, 30, 35, or 40 mg/kg rifampicin daily over 2 weeks, supplemented with standard doses of isoniazid, pyrazinamide, and ethambutol in the second week. This study aimed at characterizing rifampicin pharmacokinetics observed in HIGHRIF1 using nonlinear mixed effects modeling. The final population pharmacokinetic model included an enzyme turnover model accounting for time-dependent elimination due to autoinduction, concentration-dependent clearance, and dose-dependent bioavailability. The relationship between clearance and concentration was characterized by a Michaelis-Menten relationship. The relationship between bioavailability and dose was described using an Emax relationship. The model will be key in determining exposure-response relationships for rifampicin and should be considered when designing future trials and when treating future patients with high-dose rifampicin.
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Affiliation(s)
- Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andreas H Diacon
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and MRC Centre for TB Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa and TASK Applied Sciences, Cape Town, South Africa
| | - Rodney Dawson
- Department of Respiratory Medicine, University of Cape Town, Cape Town, South Africa and The Lung Institute, Cape Town, South Africa
| | | | - Martin J Boeree
- Department of Lung Diseases, Radboud University Medical Center, Nijmegen, the Netherlands and University Centre for Chronic Diseases Dekkerswald, Groesbeek, the Netherlands
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van Zyl-Smit RN, Esmail A, Bateman ME, Dawson R, Goldin J, van Rikxoort E, Douoguih M, Pau MG, Sadoff JC, McClain JB, Snowden MA, Benko J, Hokey DA, Rutkowski KT, Graves A, Shepherd B, Ishmukhamedov S, Kagina BMN, Abel B, Hanekom WA, Scriba TJ, Bateman ED. Safety and Immunogenicity of Adenovirus 35 Tuberculosis Vaccine Candidate in Adults with Active or Previous Tuberculosis. A Randomized Trial. Am J Respir Crit Care Med 2017; 195:1171-1180. [PMID: 28060545 DOI: 10.1164/rccm.201603-0654oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 01/13/2023] Open
Abstract
RATIONALE Administration of tuberculosis (TB) vaccines in participants with previous or current pulmonary TB may have the potential for causing harmful postvaccination immunologic (Koch-type) reactions. OBJECTIVES To assess the safety and immunogenicity of three dose levels of the AERAS-402 live, replication-deficient adenovirus 35-vectored TB candidate vaccine, containing three mycobacterial antigens, in individuals with current or previous pulmonary TB. METHODS We performed a phase II randomized, placebo-controlled, double-blinded dose-escalation study in an HIV-negative adult South African cohort (n = 72) with active pulmonary TB (on treatment for 1-4 mo) or pulmonary TB treated at least 12 months before study entry and considered cured. Safety endpoints included clinical assessment, flow volume curves, diffusing capacity of the lung for carbon monoxide, pulse oximetry, chest radiograph, and high-resolution thoracic computerized tomography scans. Cytokine expression by CD4 and CD8 T cells, after stimulation with Ag85A, Ag85B, and TB10.4 peptide pools, was examined by intracellular cytokine staining. MEASUREMENTS AND MAIN RESULTS No apparent temporal or dose-related changes in clinical status (specifically acute, Koch phenomenon-like reactions), lung function, or radiology attributable to vaccine were observed. Injection site reactions were mild or moderate. Hematuria (by dipstick only) occurred in 25 (41%) of 61 AERAS-402 recipients and 3 (27%) of 11 placebo recipients, although no gross hematuria was reported. AERAS-402 induced robust CD8+ and moderate CD4+ T-cell responses, mainly to Ag85B in both vaccine groups. CONCLUSIONS Administration of the AERAS-402 candidate TB vaccine to participants with current or previous pulmonary TB induced a robust immune response and is not associated with clinically significant pulmonary complications. Clinical trial registered with www.clinicaltrials.gov (NCT 02414828) and in the South African National Clinical Trials Register ( www.sanctr.gov.za DOH 27-0808-2060).
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Affiliation(s)
- Richard N van Zyl-Smit
- 1 University of Cape Town Lung Institute, Division of Pulmonology, Department of Medicine
| | - Aliasgar Esmail
- 1 University of Cape Town Lung Institute, Division of Pulmonology, Department of Medicine
| | - Mary E Bateman
- 1 University of Cape Town Lung Institute, Division of Pulmonology, Department of Medicine
| | - Rodney Dawson
- 1 University of Cape Town Lung Institute, Division of Pulmonology, Department of Medicine
| | | | - Eva van Rikxoort
- 3 Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Macaya Douoguih
- 4 Crucell Holland B.V., a Janssen Pharmaceutical company of Johnson & Johnson, Leiden, the Netherlands
| | - Maria Grazia Pau
- 4 Crucell Holland B.V., a Janssen Pharmaceutical company of Johnson & Johnson, Leiden, the Netherlands
| | - Jerald C Sadoff
- 4 Crucell Holland B.V., a Janssen Pharmaceutical company of Johnson & Johnson, Leiden, the Netherlands
| | | | | | | | | | | | | | | | | | - Benjamin M N Kagina
- 6 South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, and.,7 Vaccines for Africa Initiative, Division of Medical Microbiology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian Abel
- 6 South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, and.,8 Singapore Immunology Network, Agency for Science, Technology and Research, Singapore
| | - Willem A Hanekom
- 6 South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, and
| | - Thomas J Scriba
- 6 South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, and
| | - Eric D Bateman
- 1 University of Cape Town Lung Institute, Division of Pulmonology, Department of Medicine
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Cudahy PGT, Dawson R, Allwood BW, Maartens G, Wilson D. Diagnostic Outcomes After Chest Radiograph Interpretation in Patients With Suspected Tuberculosis and Negative Sputum Smears in a High-Burden Human Immunodeficiency Virus and Tuberculosis Setting. Open Forum Infect Dis 2017; 4:ofx123. [PMID: 28721354 PMCID: PMC5508775 DOI: 10.1093/ofid/ofx123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/16/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evaluation of patients with suspected tuberculosis and negative sputum smears for acid-fast bacilli (AFB) is challenging, especially in high human immunodeficiency virus coinfection settings where sputum smears have lower sensitivity for detecting AFB. METHODS We examined the utility of chest radiographs for detecting smear-negative pulmonary tuberculosis. Three hundred sixty sputum smear-negative patients who were referred from primary care clinics in the KwaZulu-Natal province of South Africa were evaluated. Chest radiographs were read by experienced pulmonologists using a previously validated Chest X-Ray Reading and Recording System (CRRS). RESULTS Agreement between observers using CRRS was high at 91% with a Cohen's kappa of 0.64 (95% confidence interval [CI] = 0.52-0.76). Against a reference standard of sputum culture, sensitivity was 93% (95% CI = 86%-97%), whereas specificity was 14% (95% CI = 10%-19%). Performance against clinical diagnosis (following World Health Organization guidelines) was similar with sensitivity of 92% (95% CI = 88%-95%) and specificity of 20% (95% CI = 13%-28%). CONCLUSION The low specificity of CRRS in this setting indicates poor diagnostic utility for detecting pulmonary tuberculosis.
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Affiliation(s)
- Patrick G T Cudahy
- Section of Infectious Disease, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Rodney Dawson
- Department of Medicine, University of Cape Town Lung Institute and Division of Pulmonology, Groote Schuur Hospital, Cape Town
| | - Brian W Allwood
- Department of Medicine, University of Cape Town Lung Institute and Division of Pulmonology, Groote Schuur Hospital, Cape Town
- Department of Medicine, Division of Pulmonology, Stellenbosch University/Tygerberg Academic Hospital, Stellenbosch
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, and
| | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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48
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Abdelrahman W, Dawson R, McCourt C. A retrospective review of the management of patients with hidradenitis suppurativa in the Belfast health and social care trust, Northern Ireland. Ir Med J 2017; 110:574. [PMID: 28737315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- W Abdelrahman
- Royal Victoria Hospital, Belfast, Northern Ireland, BT12 6BA
| | - R Dawson
- Royal Victoria Hospital, Belfast, Northern Ireland, BT12 6BA
| | - C McCourt
- Royal Victoria Hospital, Belfast, Northern Ireland, BT12 6BA
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49
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Segal LN, Clemente JC, Li Y, Ruan C, Cao J, Danckers M, Morris A, Tapyrik S, Wu BG, Diaz P, Calligaro G, Dawson R, van Zyl-Smit RN, Dheda K, Rom WN, Weiden MD. Anaerobic Bacterial Fermentation Products Increase Tuberculosis Risk in Antiretroviral-Drug-Treated HIV Patients. Cell Host Microbe 2017; 21:530-537.e4. [PMID: 28366509 DOI: 10.1016/j.chom.2017.03.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/01/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023]
Abstract
Despite the immune-reconstitution with antiretroviral therapy (ART), HIV-infected individuals remain highly susceptible to tuberculosis (TB) and have an enrichment of oral anaerobes in the lung. Products of bacterial anaerobic metabolism, like butyrate and other short-chain fatty acids (SCFAs), induce regulatory T cells (Tregs). We tested whether SCFAs contribute to poor TB control in a longitudinal cohort of ART-treated HIV-infected South Africans. Increase in serum SCFAs was associated with increased TB susceptibility. SCFAs inhibited IFN-γ and IL-17A production in peripheral blood mononuclear cells from HIV-infected ART-treated individuals in response to M. tuberculosis antigen stimulation. Pulmonary SCFAs correlated with increased oral anaerobes, such as Prevotella in the lung, and with M. tuberculosis antigen-induced Tregs. Metabolites from anaerobic bacterial fermentation may, therefore, increase TB susceptibility by suppressing IFN-γ and IL-17A production during the cellular immune response to M. tuberculosis.
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Affiliation(s)
- Leopoldo N Segal
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, New York University, New York, NY 10016, USA
| | - Jose C Clemente
- Icahn Institute for Genomics and Multiscale Biology, Department of Genetics and Genomic Sciences, and Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Yonghua Li
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, New York University, New York, NY 10016, USA
| | - Chunhai Ruan
- Metabolomics Core, University of Michigan School of Medicine, Ann Arbor, MI 48105, USA
| | - Jane Cao
- Metabolomics Core, University of Michigan School of Medicine, Ann Arbor, MI 48105, USA
| | - Mauricio Danckers
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, New York University, New York, NY 10016, USA
| | - Alison Morris
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Sarah Tapyrik
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Benjamin G Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, New York University, New York, NY 10016, USA
| | - Philip Diaz
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Gregory Calligaro
- Division of Pulmonology, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town 7925, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town 7925, South Africa
| | - Richard N van Zyl-Smit
- Division of Pulmonology, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town 7925, South Africa
| | - Keertan Dheda
- Division of Pulmonology, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town 7925, South Africa
| | - William N Rom
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, New York University, New York, NY 10016, USA
| | - Michael D Weiden
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, New York University, New York, NY 10016, USA.
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50
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Boeree MJ, Heinrich N, Aarnoutse R, Diacon AH, Dawson R, Rehal S, Kibiki GS, Churchyard G, Sanne I, Ntinginya NE, Minja LT, Hunt RD, Charalambous S, Hanekom M, Semvua HH, Mpagama SG, Manyama C, Mtafya B, Reither K, Wallis RS, Venter A, Narunsky K, Mekota A, Henne S, Colbers A, van Balen GP, Gillespie SH, Phillips PPJ, Hoelscher M. High-dose rifampicin, moxifloxacin, and SQ109 for treating tuberculosis: a multi-arm, multi-stage randomised controlled trial. Lancet Infect Dis 2017; 17:39-49. [PMID: 28100438 PMCID: PMC5159618 DOI: 10.1016/s1473-3099(16)30274-2] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/12/2016] [Accepted: 07/20/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Tuberculosis is the world's leading infectious disease killer. We aimed to identify shorter, safer drug regimens for the treatment of tuberculosis. METHODS We did a randomised controlled, open-label trial with a multi-arm, multi-stage design. The trial was done in seven sites in South Africa and Tanzania, including hospitals, health centres, and clinical trial centres. Patients with newly diagnosed, rifampicin-sensitive, previously untreated pulmonary tuberculosis were randomly assigned in a 1:1:1:1:2 ratio to receive (all orally) either 35 mg/kg rifampicin per day with 15-20 mg/kg ethambutol, 20 mg/kg rifampicin per day with 400 mg moxifloxacin, 20 mg/kg rifampicin per day with 300 mg SQ109, 10 mg/kg rifampicin per day with 300 mg SQ109, or a daily standard control regimen (10 mg/kg rifampicin, 5 mg/kg isoniazid, 25 mg/kg pyrazinamide, and 15-20 mg/kg ethambutol). Experimental treatments were given with oral 5 mg/kg isoniazid and 25 mg/kg pyrazinamide per day for 12 weeks, followed by 14 weeks of 5 mg/kg isoniazid and 10 mg/kg rifampicin per day. Because of the orange discoloration of body fluids with higher doses of rifampicin it was not possible to mask patients and clinicians to treatment allocation. The primary endpoint was time to culture conversion in liquid media within 12 weeks. Patients without evidence of rifampicin resistance on phenotypic test who took at least one dose of study treatment and had one positive culture on liquid or solid media before or within the first 2 weeks of treatment were included in the primary analysis (modified intention to treat). Time-to-event data were analysed using a Cox proportional-hazards regression model and adjusted for minimisation variables. The proportional hazard assumption was tested using Schoelfeld residuals, with threshold p<0·05 for non-proportionality. The trial is registered with ClinicalTrials.gov (NCT01785186). FINDINGS Between May 7, 2013, and March 25, 2014, we enrolled and randomly assigned 365 patients to different treatment arms (63 to rifampicin 35 mg/kg, isoniazid, pyrazinamide, and ethambutol; 59 to rifampicin 10 mg/kg, isoniazid, pyrazinamide, SQ109; 57 to rifampicin 20 mg/kg, isoniazid, pyrazinamide, and SQ109; 63 to rifampicin 10 mg/kg, isoniazid, pyrazinamide, and moxifloxacin; and 123 to the control arm). Recruitment was stopped early in the arms containing SQ109 since prespecified efficacy thresholds were not met at the planned interim analysis. Time to stable culture conversion in liquid media was faster in the 35 mg/kg rifampicin group than in the control group (median 48 days vs 62 days, adjusted hazard ratio 1·78; 95% CI 1·22-2·58, p=0·003), but not in other experimental arms. There was no difference in any of the groups in time to culture conversion on solid media. 11 patients had treatment failure or recurrent disease during post-treatment follow-up: one in the 35 mg/kg rifampicin arm and none in the moxifloxacin arm. 45 (12%) of 365 patients reported grade 3-5 adverse events, with similar proportions in each arm. INTERPRETATION A dose of 35 mg/kg rifampicin was safe, reduced the time to culture conversion in liquid media, and could be a promising component of future, shorter regimens. Our adaptive trial design was successfully implemented in a multi-centre, high tuberculosis burden setting, and could speed regimen development at reduced cost. FUNDING The study was funded by the European and Developing Countries Clinical Trials partnership (EDCTP), the German Ministry for Education and Research (BmBF), and the Medical Research Council UK (MRC).
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Affiliation(s)
- Martin J Boeree
- Department of Lung Diseases, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany,German Center for Infection Research, Partner Site Munich, Germany
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Andreas H Diacon
- Centre for Clinical Tuberculosis Research, Department of Science and Technology and National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Rodney Dawson
- Centre for Tuberculosis Research Innovation, University of Cape Town, Grote Schuur, South Africa
| | | | - Gibson S Kibiki
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Tumaini University, Moshi, Tanzania
| | - Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa,School of Public Health, University of Witwatersrand, Johannesburg, South Africa,Department of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Sanne
- Helen Joseph Hospital, Johannesburg, South Africa
| | - Nyanda E Ntinginya
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania
| | | | - Robert D Hunt
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, UK
| | | | - Madeleine Hanekom
- Centre for Clinical Tuberculosis Research, Department of Science and Technology and National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Hadija H Semvua
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Tumaini University, Moshi, Tanzania
| | | | - Christina Manyama
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Bariki Mtafya
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland,University of Basel, Basel, Switzerland
| | | | - Amour Venter
- MRC Centre for Tuberculosis Research, University of Stellenbosch, Tygerberg, South Africa
| | - Kim Narunsky
- Centre for Tuberculosis Research Innovation, University of Cape Town, Grote Schuur, South Africa
| | - Anka Mekota
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Sonja Henne
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Angela Colbers
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | | | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany,German Center for Infection Research, Partner Site Munich, Germany
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