1
|
Gillespie SH. Improving outcomes for multidrug-resistant TB: the role of integrated systems. Int J Tuberc Lung Dis 2023; 27:1-2. [PMID: 36853140 DOI: 10.5588/ijtld.22.0556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- S H Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| |
Collapse
|
2
|
Mbelele PM, Sabiiti W, Heysell SK, Sauli E, Mpolya EA, Mfinanga S, Gillespie SH, Addo KK, Kibiki G, Sloan DJ, Mpagama SG. Use of a molecular bacterial load assay to distinguish between active TB and post-TB lung disease. Int J Tuberc Lung Dis 2022; 26:276-278. [PMID: 35197168 PMCID: PMC8886960 DOI: 10.5588/ijtld.21.0459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- P M Mbelele
- Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, Tanzania, Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
| | - W Sabiiti
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - E Sauli
- Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
| | - E A Mpolya
- Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
| | - S Mfinanga
- Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania, National Institute for Medical Research (NIMR), Muhimbili Center, Dar es salaam, Tanzania
| | - S H Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| | - K K Addo
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - G Kibiki
- Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, Tanzania, East African Health Research Commission (EAHRC), Bujumbura, Burundi
| | - D J Sloan
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| | - S G Mpagama
- Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, Tanzania, Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
| |
Collapse
|
3
|
Pitcher MJ, Dobson SA, Kelsey TW, Chaplain J, Sloan DJ, Gillespie SH, Bowness R. How mechanistic in silico modelling can improve our understanding of TB disease and treatment. Int J Tuberc Lung Dis 2021; 24:1145-1150. [PMID: 33172521 DOI: 10.5588/ijtld.20.0107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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
TB is one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent. Decreasing the length of time for TB treatment is an important step towards the goal of reducing mortality. Mechanistic in silico modelling can provide us with the tools to explore gaps in our knowledge, with the opportunity to model the complicated within-host dynamics of the infection, and simulate new treatment strategies. Significant insight has been gained using this form of modelling when applied to other diseases - much can be learned in infection research from these advances.
Collapse
Affiliation(s)
- M J Pitcher
- School of Computer Science, University of St Andrews, St Andrews, Department of Immunobiology, King´s College London, London
| | - S A Dobson
- School of Computer Science, University of St Andrews, St Andrews
| | - T W Kelsey
- School of Computer Science, University of St Andrews, St Andrews
| | - J Chaplain
- School of Mathematics, University of St Andrews, St Andrews
| | - D J Sloan
- School of Medicine, University of St Andrews, St Andrews
| | - S H Gillespie
- School of Medicine, University of St Andrews, St Andrews
| | - R Bowness
- School of Medicine, University of St Andrews, St Andrews, Department of Mathematical Sciences, University of Bath, Bath, UK
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Parcell BJ, Gillespie SH, Pettigrew KA, Holden MTG. Clinical perspectives in integrating whole-genome sequencing into the investigation of healthcare and public health outbreaks - hype or help? J Hosp Infect 2020; 109:1-9. [PMID: 33181280 PMCID: PMC7927979 DOI: 10.1016/j.jhin.2020.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 01/23/2023]
Abstract
Outbreaks pose a significant risk to patient safety as well as being costly and time consuming to investigate. The implementation of targeted infection prevention and control measures relies on infection prevention and control teams having access to rapid results that detect resistance accurately, and typing results that give clinically useful information on the relatedness of isolates. At present, determining whether transmission has occurred can be a major challenge. Conventional typing results do not always have sufficient granularity or robustness to define strains unequivocally, and sufficient epidemiological data are not always available to establish links between patients and the environment. Whole-genome sequencing (WGS) has emerged as the ultimate genotyping tool, but has not yet fully crossed the divide between research method and routine clinical diagnostic microbiological technique. A clinical WGS service was officially established in 2014 as part of the Scottish Healthcare Associated Infection Prevention Institute to confirm or refute outbreaks in hospital settings from across Scotland. This article describes the authors' experiences with the aim of providing new insights into practical application of the use of WGS to investigate healthcare and public health outbreaks. Solutions to overcome barriers to implementation of this technology in a clinical environment are proposed.
Collapse
Affiliation(s)
- B J Parcell
- Ninewells Hospital and Medical School, Dundee, UK.
| | - S H Gillespie
- School of Medicine, University of St Andrews, St Andrews, UK
| | - K A Pettigrew
- School of Medicine, University of St Andrews, St Andrews, UK
| | - M T G Holden
- School of Medicine, University of St Andrews, St Andrews, UK
| |
Collapse
|
6
|
Murphy ME, Wills GH, Murthy S, Louw C, Bateson ALC, Hunt RD, McHugh TD, Nunn AJ, Meredith SK, Mendel CM, Spigelman M, Crook AM, Gillespie SH. Gender differences in tuberculosis treatment outcomes: a post hoc analysis of the REMoxTB study. BMC Med 2018; 16:189. [PMID: 30326959 PMCID: PMC6192317 DOI: 10.1186/s12916-018-1169-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 03/12/2018] [Accepted: 09/10/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In the REMoxTB study of 4-month treatment-shortening regimens containing moxifloxacin compared to the standard 6-month regimen for tuberculosis, the proportion of unfavourable outcomes for women was similar in all study arms, but men had more frequent unfavourable outcomes (bacteriologically or clinically defined failure or relapse within 18 months after randomisation) on the shortened moxifloxacin-containing regimens. The reason for this gender disparity in treatment outcome is poorly understood. METHODS The gender differences in baseline variables were calculated, as was time to smear and culture conversion and Kaplan-Meier plots were constructed. In post hoc exploratory analyses, multivariable logistic regression modelling and an observed case analysis were used to explore factors associated with both gender and unfavourable treatment outcome. RESULTS The per-protocol population included 472/1548 (30%) women. Women were younger and had lower rates of cavitation, smoking and weight (all p < 0.05) and higher prevalence of HIV (10% vs 6%, p = 0.001). They received higher doses (mg/kg) than men of rifampicin, isoniazid, pyrazinamide and moxifloxacin (p ≤ 0.005). There was no difference in baseline smear grading or mycobacterial growth indicator tube (MGIT) time to positivity. Women converted to negative cultures more quickly than men on Lowenstein-Jensen (HR 1.14, p = 0.008) and MGIT media (HR 1.19, p < 0.001). In men, the presence of cavitation, positive HIV status, higher age, lower BMI and 'ever smoked' were independently associated with unfavourable treatment outcome. In women, only 'ever smoked' was independently associated with unfavourable treatment outcome. Only for cavitation was there a gender difference in treatment outcomes by regimen; their outcome in the 4-month arms was significantly poorer compared to the 6-month treatment arm (p < 0.001). Women, with or without cavities, and men without cavities had a similar outcome on all treatment arms (p = 0.218, 0.224 and 0.689 respectively). For all other covariate subgroups, there were no differences in treatment effects for men or women. CONCLUSIONS Gender differences in TB treatment responses for the shorter regimens in the REMoxTB study may be explained by poor outcomes in men with cavitation on the moxifloxacin-containing regimens. We observed that women with cavities, or without, on the 4-month moxifloxacin regimens had similar outcomes to all patients on the standard 6-month treatment. The biological reasons for this difference are poorly understood and require further exploration.
Collapse
Affiliation(s)
- M E Murphy
- UCL Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, England, UK.
| | - G H Wills
- MRC Clinical Trials Unit at UCL, Institute for Clinical Trials and Methodology, Aviation House, 125 Kingsway, London, WC2B 6NH, England, UK
| | - S Murthy
- UCL Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, England, UK
| | - C Louw
- Madibeng Centre for Research, Brits, South Africa.,Department of Family Medicine, School of medicine, University of Pretoria, Pretoria, South Africa
| | - A L C Bateson
- UCL Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, England, UK
| | - R D Hunt
- UCL Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, England, UK
| | - T D McHugh
- UCL Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, England, UK
| | - A J Nunn
- MRC Clinical Trials Unit at UCL, Institute for Clinical Trials and Methodology, Aviation House, 125 Kingsway, London, WC2B 6NH, England, UK
| | - S K Meredith
- MRC Clinical Trials Unit at UCL, Institute for Clinical Trials and Methodology, Aviation House, 125 Kingsway, London, WC2B 6NH, England, UK
| | - C M Mendel
- Global Alliance for Tuberculosis Drug Development, New York, NY, 10005, USA
| | - M Spigelman
- Global Alliance for Tuberculosis Drug Development, New York, NY, 10005, USA
| | - A M Crook
- MRC Clinical Trials Unit at UCL, Institute for Clinical Trials and Methodology, Aviation House, 125 Kingsway, London, WC2B 6NH, England, UK
| | - S H Gillespie
- School of Medicine, Medical and Biological Sciences Building, University of St Andrews, North Haugh, St Andrews, KY16 9TF, Scotland, UK
| | | |
Collapse
|
7
|
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.
Collapse
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.
| | | |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Sabiiti W, Mtafya B, Kuchaka D, Azam K, Viegas S, Mdolo A, Farmer ECW, Khonga M, Evangelopoulos D, Honeyborne I, Rachow A, Heinrich N, Ntinginya NE, Bhatt N, Davies GR, Jani IV, McHugh TD, Kibiki G, Hoelscher M, Gillespie SH. Optimising molecular diagnostic capacity for effective control of tuberculosis in high-burden settings. Int J Tuberc Lung Dis 2018; 20:1004-9. [PMID: 27393531 DOI: 10.5588/ijtld.15.0951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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
The World Health Organization's 2035 vision is to reduce tuberculosis (TB) associated mortality by 95%. While low-burden, well-equipped industrialised economies can expect to see this goal achieved, it is challenging in the low- and middle-income countries that bear the highest burden of TB. Inadequate diagnosis leads to inappropriate treatment and poor clinical outcomes. The roll-out of the Xpert(®) MTB/RIF assay has demonstrated that molecular diagnostics can produce rapid diagnosis and treatment initiation. Strong molecular services are still limited to regional or national centres. The delay in implementation is due partly to resources, and partly to the suggestion that such techniques are too challenging for widespread implementation. We have successfully implemented a molecular tool for rapid monitoring of patient treatment response to anti-tuberculosis treatment in three high TB burden countries in Africa. We discuss here the challenges facing TB diagnosis and treatment monitoring, and draw from our experience in establishing molecular treatment monitoring platforms to provide practical insights into successful optimisation of molecular diagnostic capacity in resource-constrained, high TB burden settings. We recommend a holistic health system-wide approach for molecular diagnostic capacity development, addressing human resource training, institutional capacity development, streamlined procurement systems, and engagement with the public, policy makers and implementers of TB control programmes.
Collapse
Affiliation(s)
- W Sabiiti
- School of Medicine, University of St Andrews, St Andrews, UK
| | - B Mtafya
- Mbeya Medical Research Centre, National Institute of Medical Research, Mbeya, Tanzania
| | - D Kuchaka
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - K Azam
- Instituto Nacional de Saude, Ministerio da Saude, Maputo, Mozambique
| | - S Viegas
- Instituto Nacional de Saude, Ministerio da Saude, Maputo, Mozambique
| | - A Mdolo
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - E C W Farmer
- School of Medicine, University of St Andrews, St Andrews, UK
| | - M Khonga
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - D Evangelopoulos
- Centre for Clinical Microbiology, University College London, London, UK
| | - I Honeyborne
- Centre for Clinical Microbiology, University College London, London, UK
| | - A Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany; German Center for Infection Research, Munich, Germany
| | - N Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany; German Center for Infection Research, Munich, Germany
| | - N E Ntinginya
- Mbeya Medical Research Centre, National Institute of Medical Research, Mbeya, Tanzania
| | - N Bhatt
- Instituto Nacional de Saude, Ministerio da Saude, Maputo, Mozambique
| | - G R Davies
- College of Medicine, University of Malawi, Blantyre, Malawi; Institutes of Global Health & Translational Medicine, University of Liverpool, Liverpool, UK
| | - I V Jani
- Instituto Nacional de Saude, Ministerio da Saude, Maputo, Mozambique
| | - T D McHugh
- Centre for Clinical Microbiology, University College London, London, UK
| | - G Kibiki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - M Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany; German Center for Infection Research, Munich, Germany
| | - S H Gillespie
- School of Medicine, University of St Andrews, St Andrews, UK
| | | |
Collapse
|
10
|
Parcell BJ, Oravcova K, Pinheiro M, Holden MTG, Phillips G, Turton JF, Gillespie SH. Pseudomonas aeruginosa intensive care unit outbreak: winnowing of transmissions with molecular and genomic typing. J Hosp Infect 2017; 98:282-288. [PMID: 29229490 PMCID: PMC5840502 DOI: 10.1016/j.jhin.2017.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/03/2017] [Indexed: 12/29/2022]
Abstract
Background Pseudomonas aeruginosa healthcare outbreaks can be time consuming and difficult to investigate. Guidance does not specify which typing technique is most practical for decision-making. Aim To explore the usefulness of whole-genome sequencing (WGS) in the investigation of a P. aeruginosa outbreak, describing how it compares with pulsed-field gel electrophoresis (PFGE) and variable number tandem repeat (VNTR) analysis. Methods Six patient isolates and six environmental samples from an intensive care unit (ICU) positive for P. aeruginosa over two years underwent VNTR, PFGE and WGS. Findings VNTR and PFGE were required to fully determine the potential source of infection and rule out others. WGS results unambiguously distinguished linked isolates, giving greater assurance of the transmission route between wash-hand basin water and two patients, supporting the control measures employed. Conclusion WGS provided detailed information without the need for further typing. When allied to epidemiological information, WGS can be used to understand outbreak situations rapidly and with certainty. Implementation of WGS in real-time would be a major advance in day-to-day practice. It could become a standard of care as it becomes more widespread due to its reproducibility and lower costs.
Collapse
Affiliation(s)
- B J Parcell
- Ninewells Hospital & Medical School, Dundee, UK.
| | - K Oravcova
- School of Medicine, University of St Andrews, St Andrews, UK
| | - M Pinheiro
- School of Medicine, University of St Andrews, St Andrews, UK
| | - M T G Holden
- School of Medicine, University of St Andrews, St Andrews, UK
| | - G Phillips
- Ninewells Hospital & Medical School, Dundee, UK
| | - J F Turton
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, Colindale, UK
| | - S H Gillespie
- School of Medicine, University of St Andrews, St Andrews, UK
| |
Collapse
|
11
|
Tweed CD, Wills G, Crook AM, Meredith SK, Nunn AJ, Mendel CM, Murray SR, McHugh TD, Gillespie SH. S91 Liver function tests during tuberculosis treatment and the implications on monitoring for hepatotoxicity. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
12
|
Tweed CD, Wills G, Crook AM, Meredith SK, Nunn AJ, Mendel CM, Murray SR, McHugh TD, Gillespie SH. P119 Using adverse events in a tuberculosis trial to describe the tolerability of standard therapy. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.262] [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: 11/04/2022]
|
13
|
Lipworth S, Hammond RJH, Baron VO, Hu Y, Coates A, Gillespie SH. Defining dormancy in mycobacterial disease. Tuberculosis (Edinb) 2016; 99:131-142. [PMID: 27450015 DOI: 10.1016/j.tube.2016.05.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/06/2016] [Accepted: 05/23/2016] [Indexed: 11/19/2022]
Abstract
Tuberculosis remains a threat to global health and recent attempts to shorten therapy have not succeeded mainly due to cases of clinical relapse. This has focussed attention on the importance of "dormancy" in tuberculosis. There are a number of different definitions of the term and a similar multiplicity of different in vitro and in vivo models. The danger with this is the implicit assumption of equivalence between the terms and models, which will make even more difficult to unravel this complex conundrum. In this review we summarise the main models and definitions and their impact on susceptibility of Mycobacterium tuberculosis. We also suggest a potential nomenclature for debate. Dormancy researchers agree that factors underpinning this phenomenon are complex and nuanced. If we are to make progress we must agree the terms to be used and be consistent in using them.
Collapse
Affiliation(s)
- S Lipworth
- School of Medicine, University of St Andrews, Biomedical Science Building, North Haugh, St Andrews KY16 9TF, United Kingdom
| | - R J H Hammond
- School of Medicine, University of St Andrews, Biomedical Science Building, North Haugh, St Andrews KY16 9TF, United Kingdom
| | - V O Baron
- School of Medicine, University of St Andrews, Biomedical Science Building, North Haugh, St Andrews KY16 9TF, United Kingdom
| | - Yanmin Hu
- Institute for Infection and Immunity, St George's, University of London, London SW17 ORE, United Kingdom
| | - A Coates
- Institute for Infection and Immunity, St George's, University of London, London SW17 ORE, United Kingdom
| | - S H Gillespie
- School of Medicine, University of St Andrews, Biomedical Science Building, North Haugh, St Andrews KY16 9TF, United Kingdom.
| |
Collapse
|
14
|
Honeyborne I, Eckold C, Gillespie SH, Lipman M, Pym A, McHugh TD. S59 Dramatic decline in plasma small RNA concentration in HIV-infected and uninfected individuals receiving anti-tuberculosis therapy: a putative biomarker of treatment response. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.66] [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: 11/04/2022]
|
15
|
Shorten RJ, McGregor AC, Platt S, Jenkins C, Lipman MCI, Gillespie SH, Charalambous BM, McHugh TD. When is an outbreak not an outbreak? Fit, divergent strains of Mycobacterium tuberculosis display independent evolution of drug resistance in a large London outbreak. J Antimicrob Chemother 2012; 68:543-9. [DOI: 10.1093/jac/dks430] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
16
|
Murphy ME, Singh KP, Laurenzi M, Brown M, Gillespie SH. Managing malaria in tuberculosis patients on fluoroquinolone-containing regimens: assessing the risk of QT prolongation [Review article]. Int J Tuberc Lung Dis 2012; 16:144-9, i-iii. [DOI: 10.5588/ijtld.11.0074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | - M. Laurenzi
- Global Alliance for TB Drug Development, New York, New York, USA
| | - M. Brown
- London School of Hygiene & Tropical Medicine, London, UK
| | - S. H. Gillespie
- University College, London, UK; and School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| |
Collapse
|
17
|
van Ingen J, Aarnoutse RE, Donald PR, Diacon AH, Dawson R, Plemper van Balen G, Gillespie SH, Boeree MJ. Why Do We Use 600 mg of Rifampicin in Tuberculosis Treatment? Clin Infect Dis 2011; 52:e194-9. [DOI: 10.1093/cid/cir184] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
18
|
Perrin FMR, Woodward N, Phillips PPJ, McHugh TD, Nunn AJ, Lipman MCI, Gillespie SH. Radiological cavitation, sputum mycobacterial load and treatment response in pulmonary tuberculosis. Int J Tuberc Lung Dis 2010; 14:1596-1602. [PMID: 21144246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
SETTING Royal Free Hospital, London. OBJECTIVE To investigate the relationship between sputum mycobacterial load, assessed by time to positivity (TTP) in liquid culture, radiological cavitation and change in sputum bacterial load in response to anti-tuberculosis treatment. DESIGN The study was conducted on 95 patients treated for sputum culture-positive pulmonary tuberculosis (TB), with pre-treatment TTP and baseline chest X-ray (CXR). Of these, 31 had chest computed tomography scans assessed for number and volume of cavities. The microbiological treatment response was measured in 56 patients with serial TTP, and related to baseline radiological cavitation. RESULTS Cavitation was present in 48% of patients, and was associated with a shorter TTP at baseline (P < 0.001). Patients with more cavities and greater total cavitary volume had a shorter TTP (P < 0.001 for both). No difference was demonstrated in the rate of change in TTP on treatment (P = 0.36) between patients with and without cavities. CONCLUSION This study confirms that cavitation is associated with higher baseline sputum mycobacterial load. The rate of decline in bacterial load in response to treatment is similar in patients with and without radiologically demonstrable cavities, suggesting that response to, and hence duration of, effective treatment may be predicted by the initial number of organisms present in the sputum.
Collapse
Affiliation(s)
- F M R Perrin
- Department of Infection, Royal Free Campus, University College London, London, UK
| | | | | | | | | | | | | |
Collapse
|
19
|
Affiliation(s)
- D M O'Sullivan
- Department of Infection, Royal Free Campus, University College London, Rowland Hill Street, Hampstead, London NW3 2PF, UK
| | - T D McHugh
- Department of Infection, Royal Free Campus, University College London, Rowland Hill Street, Hampstead, London NW3 2PF, UK
| | - S H Gillespie
- Health Protection Agency, Regional Microbiology Network, Holborn Gate, London WC1V 7PP, UK.,Department of Infection, Royal Free Campus, University College London, Rowland Hill Street, Hampstead, London NW3 2PF, UK
| |
Collapse
|
20
|
Perrin FMR, Breen RAM, McHugh TD, Gillespie SH, Lipman MCI. Are patients on treatment for pulmonary TB who stop expectorating sputum genuinely culture negative? Thorax 2010; 64:1009-10. [PMID: 19864550 DOI: 10.1136/thx.2009.115915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
21
|
Abstract
Members of the Burkholderia cepacia complex (Bcc) are highly resistant to many antibacterial agents and infection can be difficult to eradicate. A coordinated approach has been used to measure the fitness of Bcc bacteria isolated from cystic fibrosis (CF) patients with chronic Bcc infection using methods relevant to Bcc growth and survival conditions. Significant differences in growth rate were observed among isolates; slower growth rates were associated with isolates that exhibited higher MICs and were resistant to more antimicrobial classes. The nucleotide sequences of the quinolone resistance-determining region of gyrA in the isolates were determined and the ciprofloxacin MIC correlated with amino acid substitutions at codons 83 and 87. Biologically relevant methods for fitness measurement were developed and could be applied to investigate larger numbers of clinical isolates. These methods were determination of planktonic growth rate, biofilm formation, survival in water and survival during drying. We also describe a method to determine mutation rate in Bcc bacteria. Unlike in Pseudomonas aeruginosa where hypermutability has been detected in strains isolated from CF patients, we were unable to demonstrate hypermutability in this panel of Burkholderia cenocepacia and Burkholderia multivorans isolates.
Collapse
Affiliation(s)
- C F Pope
- Centre for Clinical Microbiology, University College London, Rowland Hill Street, London NW3 2QG, UK
| | - S H Gillespie
- Regional Microbiology Network, Health Protection Agency, Holborn Gate, London WC1V 7PP, UK.,Centre for Clinical Microbiology, University College London, Rowland Hill Street, London NW3 2QG, UK
| | - J E Moore
- School of Biomedical Sciences, University of Ulster, Cromore Road, Coleraine BT52 1SA, UK.,Department of Bacteriology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK
| | - T D McHugh
- Centre for Clinical Microbiology, University College London, Rowland Hill Street, London NW3 2QG, UK
| |
Collapse
|
22
|
Craig SE, Bettinson H, Sabin CA, Gillespie SH, Lipman MCI. Think TB! Is the diagnosis of pulmonary tuberculosis delayed by the use of antibiotics? Int J Tuberc Lung Dis 2009; 13:208-213. [PMID: 19146749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
SETTING Effective tuberculosis (TB) control requires prompt diagnosis of infectious cases through early suspicion of pulmonary TB in all subjects with suspected respiratory infection. OBJECTIVE To test our hypothesis that prior antibiotic treatment for presumed bacterial infection leads to a delay in diagnosing TB in a European country with low TB incidence. DESIGN Adults with culture-confirmed pulmonary TB at a single metropolitan centre were assessed for the impact of any previous antibiotic treatment on symptoms and the time to starting specific anti-tuberculosis treatment. RESULTS Of 83 patients, 42 (51%) received antibiotics prior to TB diagnosis, with symptomatic improvement reported in 20 of the 42 (48%) patients. This was unrelated to specific drug class. Although the median time to diagnosis in subjects receiving antibiotics was prolonged (P=0.001), this was not predicted by treatment response. In 94% of cases, the initial chest radiograph was suggestive of TB infection. CONCLUSION Patients receiving antibiotics prior to TB confirmation experience a process-related delay in starting treatment. To minimise the risk of ongoing TB transmission, we propose that clinicians should include TB in their differential diagnosis and initiate simple, TB-focused investigations early on in the diagnostic process.
Collapse
Affiliation(s)
- S E Craig
- Department of Respiratory Medicine, Royal Free Hospital, and Department of Medical Statistics and Epidemiology, Royal Free & University College Medical School, London, UK.
| | | | | | | | | |
Collapse
|
23
|
Amin AK, Manuel RJ, Ison CA, Woodham R, Shemko M, Maguire H, Giraudon I, Forde J, Gillespie SH. Audit of laboratory diagnostic methods for syphilis in England and Wales. Sex Transm Infect 2008; 85:88-91. [DOI: 10.1136/sti.2008.033159] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|
24
|
O'Sullivan DM, Hinds J, Butcher PD, Gillespie SH, McHugh TD. Mycobacterium tuberculosis DNA repair in response to subinhibitory concentrations of ciprofloxacin. J Antimicrob Chemother 2008; 62:1199-202. [PMID: 18799471 DOI: 10.1093/jac/dkn387] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To investigate how the SOS response, an error-prone DNA repair pathway, is expressed following subinhibitory quinolone treatment of Mycobacterium tuberculosis. METHODS Genome-wide expression profiling followed by quantitative RT (qRT)-PCR was used to study the effect of ciprofloxacin on M. tuberculosis gene expression. RESULTS Microarray analysis showed that 16/110 genes involved in DNA protection, repair and recombination were up-regulated. There appeared to be a lack of downstream genes involved in the SOS response. qRT-PCR detected an induction of lexA and recA after 4 h and of dnaE2 after 24 h of subinhibitory treatment. CONCLUSIONS The pattern of gene expression observed following subinhibitory quinolone treatment differed from that induced after other DNA-damaging agents (e.g. mitomycin C). The expression of the DnaE2 polymerase response was significantly delayed following subinhibitory quinolone exposure.
Collapse
Affiliation(s)
- D M O'Sullivan
- Centre for Medical Microbiology, Department of Infection, Royal Free Campus, University College London, Rowland Hill Street, Hampstead, London NW3 2PF, UK
| | | | | | | | | |
Collapse
|
25
|
O'Sullivan DM, McHugh TD, Gillespie SH. The effect of oxidative stress on the mutation rate of Mycobacterium tuberculosis with impaired catalase/peroxidase function. J Antimicrob Chemother 2008; 62:709-12. [DOI: 10.1093/jac/dkn259] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
26
|
Breen RAM, Barry SM, Smith CJ, Shorten RJ, Dilworth JP, Cropley I, McHugh TD, Gillespie SH, Janossy G, Lipman MCI. Clinical application of a rapid lung-orientated immunoassay in individuals with possible tuberculosis. Thorax 2008; 63:67-71. [PMID: 17675319 DOI: 10.1136/thx.2007.078857] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Immunological ex vivo assays to diagnose tuberculosis (TB) have great potential but have largely been blood-based and poorly evaluated in active TB. Lung sampling enables combined microbiological and immunological testing and uses higher frequency antigen-specific responses than in blood. METHODS A prospective evaluation was undertaken of a flow cytometric assay measuring the percentage of interferon-gamma synthetic CD4+ lymphocytes following stimulation with purified protein derivative of Mycobacterium tuberculosis (PPD) in bronchoalveolar lavage fluid from 250 sputum smear-negative individuals with possible TB. A positive assay was defined as >1.5%. RESULTS Of those who underwent lavage and were diagnosed with active TB, 95% (106/111) had a positive immunoassay (95% CI 89% to 98%). In 139 individuals deemed not to have active TB, 105 (76%) were immunoassay negative (95% CI 68% to 82%). Of the remaining 24% (34 cases) with a positive immunoassay, a substantial proportion had evidence of untreated TB; in two of these active TB was subsequently diagnosed. Assay performance was unaffected by HIV status, disease site or BCG vaccination. In culture-positive pulmonary cases, response to PPD was more sensitive than nucleic acid amplification testing (94% vs 73%). The use of early secretory antigen target-6 (ESAT-6) responses in 71 subjects was no better than PPD, and 19% of those with culture-confirmed TB and a positive PPD immunoassay had no detectable response to ESAT-6. CONCLUSIONS These findings suggest that lung-orientated immunological investigation is a potentially powerful tool in diagnosing individuals with sputum smear-negative active TB, regardless of HIV serostatus.
Collapse
Affiliation(s)
- R A M Breen
- Department of Immunology, Royal Free and University College Medical School, London, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
O'Sullivan DM, Sander C, Shorten RJ, Gillespie SH, Hill AVS, McHugh TD, McShane H, Tchilian EZ. Evaluation of liquid culture for quantitation of Mycobacterium tuberculosis in murine models. Vaccine 2007; 25:8203-5. [PMID: 17980937 DOI: 10.1016/j.vaccine.2007.09.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 09/12/2007] [Indexed: 11/18/2022]
Abstract
Quantitation of bacterial load in tissues is essential for experimental investigation of Mycobacterium tuberculosis infection and immunity. We have used an automated liquid culture system to determine the number of colony forming units (CFU) in murine tissues and compared the results to those obtained by conventional plating on Middlebrook agar. There is an overall good correlation between results obtained by the two methods. Although less consistency and more contamination was observed in the automated liquid culture, the method is more sensitive, less labour intensive and allows the processing of large numbers of samples.
Collapse
|
28
|
Williams KJ, Ling CL, Jenkins C, Gillespie SH, McHugh TD. A paradigm for the molecular identification of Mycobacterium species in a routine diagnostic laboratory. J Med Microbiol 2007; 56:598-602. [PMID: 17446280 DOI: 10.1099/jmm.0.46855-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to improve the identification ofMycobacteriumspecies in the context of a UK teaching hospital. Real-time PCR assays were established to enable the rapid differentiation betweenMycobacterium tuberculosis(MTB) complex andMycobacteriumspecies other thantuberculosis(MOTT), followed by 16S rRNA gene sequencing for the speciation of MOTT. Real-time PCR assays gave comparable results to those from the reference laboratory. The implementation of these PCR assays using an improved bead extraction method has enhanced the mycobacterial diagnostic service at the Royal Free Hospital by providing a rapid means of differentiating between MTB complex and MOTT, and would be simple to implement in similar laboratories. Sequence analysis successfully identified a range ofMycobacteriumspp. representative of those encountered in the clinical setting of the authors, includingMycobacterium aviumcomplex,Mycobacterium fortuitumgroup,Mycobacterium chelonae–Mycobacterium abscessusgroup,Mycobacterium xenopiandMycobacterium gordonae. It provides a useful tool for the identification of MOTT when clinically indicated.
Collapse
Affiliation(s)
- K J Williams
- Department of Microbiology, Royal Free Hospital, London NW3 2QG, UK
| | - C L Ling
- Department of Microbiology, Royal Free Hospital, London NW3 2QG, UK
| | - C Jenkins
- Department of Microbiology, Royal Free Hospital, London NW3 2QG, UK
| | - S H Gillespie
- Centre for Medical Microbiology, Hampstead Campus, University College London, London NW3 2PF, UK
| | - T D McHugh
- Centre for Medical Microbiology, Hampstead Campus, University College London, London NW3 2PF, UK
| |
Collapse
|
29
|
Uriyo J, Gosling RD, Maddox V, Sam NE, Schimana W, Gillespie SH, McHugh TD. Prevalences of Pneumocystis jiroveci, Mycobacterium tuberculosis and Streptococcus pneumoniae infection in children with severe pneumonia, in a tertiary referral hospital in northern Tanzania. Ann Trop Med Parasitol 2006; 100:245-9. [PMID: 16630382 DOI: 10.1179/136485913x13789813917580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
At the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania, both the number of paediatric cases of lower respiratory-tract infection (LRTI) and the associated mortality increased between 2000 and 2001. Molecular diagnostic tools were used to enhance the identification of the pathogens responsible for this perceived increase. All 72 children aged between 2 and 60 months who were admitted with LRTI over a 3-month period were enrolled in the study. Induced sputum was collected from each child and, if the parents consented, the subjects were also tested for HIV. The sputum samples were each checked for bacteria by culture and, in amplification assays, for the DNA of Pneumocystis jiroveci, Mycobacterium tuberculosis and Streptococcus pneumoniae. Twenty-two (50%) of the 44 children tested for HIV had HIV-1 antibodies. Although only two children, both aged <6 months, were found PCR-positive for P. jiroveci, and only one was found positive for M. tuberculosis, 46 (including one of those found positive for P. jiroveci and the child found positive for M. tuberculosis) were found PCR-positive for S. pneumoniae. It therefore appears that most paediatric cases of LRTI who present at the hospital are attributable to S. pneumoniae, and that infections with this pathogen are entirely responsible for the observed increase in the incidence of LTRI in the local children. The increase seen in LRTI-associated mortality among the children may be the result of pneumococcal antibiotic resistance.
Collapse
Affiliation(s)
- J Uriyo
- Department of Paediatrics, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | | | | | | | | | | | | |
Collapse
|
30
|
Creer DD, Dilworth JP, Gillespie SH, Johnston AR, Johnston SL, Ling C, Patel S, Sanderson G, Wallace PG, McHugh TD. Aetiological role of viral and bacterial infections in acute adult lower respiratory tract infection (LRTI) in primary care. Thorax 2005; 61:75-9. [PMID: 16227331 PMCID: PMC2080713 DOI: 10.1136/thx.2004.027441] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Lower respiratory tract infections (LRTI) are a common reason for consulting general practitioners (GPs). In most cases the aetiology is unknown, yet most result in an antibiotic prescription. The aetiology of LRTI was investigated in a prospective controlled study. METHODS Eighty adults presenting to GPs with acute LRTI were recruited together with 49 controls over 12 months. Throat swabs, nasal aspirates (patients and controls), and sputum (patients) were obtained and polymerase chain reaction (PCR) and reverse transcriptase polymerase chain reaction (RT-PCR) assays were used to detect Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, influenza viruses (AH1, AH3 and B), parainfluenza viruses 1-3, coronaviruses, respiratory syncytial virus, adenoviruses, rhinoviruses, and enteroviruses. Standard sputum bacteriology was also performed. Outcome was recorded at a follow up visit. RESULTS Potential pathogens were identified in 55 patients with LRTI (69%) and seven controls (14%; p<0.0001). The identification rate was 63% (viruses) and 26% (bacteria) for patients and 12% (p<0.0001) and 6% (p = 0.013), respectively, for controls. The most common organisms identified in the patients were rhinoviruses (33%), influenza viruses (24%), and Streptococcus pneumoniae (19%) compared with 2% (p<0.001), 6% (p = 0.013), and 4% (p = 0.034), respectively, in controls. Multiple pathogens were identified in 18 of the 80 LRTI patients (22.5%) and in two of the 49 controls (4%; p = 0.011). Atypical organisms were rarely identified. Cases with bacterial aetiology were clinically indistinguishable from those with viral aetiology. CONCLUSION Patients presenting to GPs with acute adult LRTI predominantly have a viral illness which is most commonly caused by rhinoviruses and influenza viruses.
Collapse
|
31
|
Perrin FMR, Breen RAM, Lipman MCI, Shorten RJ, Gillespie SH, McHugh TD. Is there a relationship between Mycobacterium tuberculosis strain type and TB paradoxical reaction? Thorax 2005; 60:706-7. [PMID: 16061718 PMCID: PMC1747474 DOI: 10.1136/thx.2005.044321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
32
|
McHugh TD, Batt SL, Shorten RJ, Gosling RD, Uiso L, Gillespie SH. Mycobacterium tuberculosis lineage: a naming of the parts. Tuberculosis (Edinb) 2005; 85:127-36. [PMID: 15850751 DOI: 10.1016/j.tube.2004.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2004] [Revised: 06/03/2004] [Accepted: 06/09/2004] [Indexed: 11/18/2022]
Abstract
There have been many reports of groups of related Mycobacterium tuberculosis strains described variously as lineages, families or clades. There is no objective definition of these groupings, making it impossible to define relationships between those groups with biological advantages. Here we describe two groups of related strains obtained from an epidemiological study in Tanzania, which we define as the Kilimanjaro and Meru lineages on the basis of IS6110 restriction fragment length polymorphism (RFLP), polymorphic GC rich sequence (PGRS) RFLP and mycobacterial interspersed repeat unit (MIRU) typing. We investigated the concordance between each of the typing techniques and the dispersal of the typing profiles from a core pattern. The Meru lineage is more dispersed than the Kilimanjaro lineage and we speculate that the Meru lineage is older. We suggest that this approach provides an objective definition that proves robust in this epidemiological study. Such a framework will permit associations between a lineage and clinical or bacterial phenomenon to be tested objectively. This definition will also enable new putative lineages to be objectively tested.
Collapse
Affiliation(s)
- T D McHugh
- Department of Infection, Centre for Medical Microbiology, University College London, Royal Free Campus, Rowland Hill Street, Hampstead, London NW3 2PF, UK.
| | | | | | | | | | | |
Collapse
|
33
|
Shorten RJ, Gillespie SH, Sule O, Lipman M, McHugh TD. Molecular strain typing of M. tuberculosis isolates from a suspected outbreak involving a faulty bronchoscope. J Hosp Infect 2005; 61:86-7. [PMID: 16054947 DOI: 10.1016/j.jhin.2004.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 12/20/2004] [Indexed: 11/28/2022]
|
34
|
Conaty SJ, Claxton AP, Enoch DA, Hayward AC, Lipman MCI, Gillespie SH. The interpretation of nucleic acid amplification tests for tuberculosis: do rapid tests change treatment decisions? J Infect 2005; 50:187-92. [PMID: 15780411 DOI: 10.1016/j.jinf.2004.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To describe changes in treatment decisions after receipt of nucleic acid amplification (NAA) test for the diagnosis of M. tuberculosis. METHODS Retrospective notes review of treatment decisions in patients receiving a NAA test for suspected pulmonary or non-pulmonary tuberculosis at the Royal Free Hospital in London between March 2001 and February 2002. Notes were sought on a 50% random sample of patients with both smear and NAA negative specimens and all patients with other specimen results. RESULTS Two hundred and fifty patients were tested with NAA; clinical details were obtained on 138; 61 were ever treated. Seventeen (17/18) smear-negative patients were started on treatment after a positive NAA; none of six smear-negative patients treated prior to a negative NAA result had treatment stopped. Seventeen (17/21) smear-positive patients were treated prior to NAA result and all were NAA positive; treatment was delayed in four smear-positive patients until receipt of an NAA and one NAA-negative patient was not treated. CONCLUSIONS In routine practice a positive test in an untreated smear-negative patient leads to decision to treat in almost all, but the proportion testing positive is low (8% or 17/219). In patients already on treatment negative tests did not lead to decisions to stop.
Collapse
Affiliation(s)
- S J Conaty
- Department of Primary Care and Population Science, UCL Centre for Infectious Disease Epidemiology, Royal Free and University College Medical School, Royal Free Campus, London NW3 2PF, UK.
| | | | | | | | | | | |
Collapse
|
35
|
Appelbaum PC, Gillespie SH, Burley CJ, Tillotson GS. Antimicrobial selection for community-acquired lower respiratory tract infections in the 21st century: a review of gemifloxacin. Int J Antimicrob Agents 2005; 23:533-46. [PMID: 15194123 DOI: 10.1016/j.ijantimicag.2004.02.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Community-acquired lower respiratory tract infections (LRTIs) are more prevalent in the elderly than in children and younger adults and form a significant proportion of all consultations and hospital admissions in this older age group. Furthermore, in a world of increasing life expectancy the trend seems unlikely to be reversed. Antimicrobial treatment of community-acquired pneumonia (CAP) must cover Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, and in many circumstances should also cover the intracellular (atypical) pathogens. In contrast, acute exacerbations of chronic bronchitis (AECB) are mainly associated with H. influenzae and S. pneumoniae and not with atypical bacteria: in severe cases, other Gram-negative bacteria may be involved. Frequently in LRTIs, the aetiology of the infection cannot be identified from the laboratory specimens and treatment has to be empirical. In such situations it is important to not only to use an antibiotic that covers all likely organisms, but also one that has good activity against these organisms given the local resistance patterns. Gemifloxacin is a new quinolone antibiotic that targets pneumococcal DNA gyrase and topoisomerase IV and is highly active against S. pneumoniae including penicillin-, macrolide- and many ciprofloxacin-resistant strains, as well as H. influenzae and the atypical pathogens. In clinical trials in CAP and AECB, gemifloxacin has been shown to be as effective a range of comparators and demonstrated an adverse event profile that was in line with the comparator agents. In one long-term study in AECB significantly more patients receiving gemifloxacin than clarithromycin remained free of recurrence after 26 weeks. The improved potency, broad spectrum of activity and proven clinical and bacteriological efficacy and safety profile should make it a useful agent in the 21st century battle against community-acquired LRTIs.
Collapse
Affiliation(s)
- P C Appelbaum
- Department of Pathology, Hershey Medical Center, P.O. Box 850, Hershey, PA 17033, USA.
| | | | | | | |
Collapse
|
36
|
McHugh TD, Pope CF, Ling CL, Patel S, Billington OJ, Gosling RD, Lipman MC, Gillespie SH. Prospective evaluation of BDProbeTec strand displacement amplification (SDA) system for diagnosis of tuberculosis in non-respiratory and respiratory samples. J Med Microbiol 2004; 53:1215-1219. [PMID: 15585500 DOI: 10.1099/jmm.0.45780-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Nucleic acid amplification techniques (NAATs) have been demonstrated to make significant improvements in the diagnosis of tuberculosis (TB), particularly in the time to diagnosis and the diagnosis of smear-negative TB. The BD ProbeTec strand displacement amplification (SDA) system for the diagnosis of pulmonary and non-pulmonary tuberculosis was evaluated. A total of 689 samples were analysed from patients with clinically suspected TB. Compared with culture, the sensitivity and specificity for pulmonary samples were 98 and 89 %, and against final clinical diagnosis 93 and 92 %, respectively. This assay has undergone limited evaluation for non-respiratory samples and so 331 non-respiratory samples were tested, identifying those specimens that were likely to yield a useful result. These were CSF (n = 104), fine needle aspirates (n = 64) and pus (n = 41). Pleural fluid (n = 47) was identified as a poor specimen. A concern in using the SDA assay was that low-positive samples were difficult to interpret; 7.8 % of specimens fell into this category. Indeed, 64 % of the discrepant results, when compared to final clinical diagnosis, could be assigned as low-positive samples. Specimen type did not predict likelihood of a sample being in the low-positive zone. Although the manufacturers do not describe the concept of a low-positive zone, we have found that it aids clinical diagnosis.
Collapse
Affiliation(s)
- T D McHugh
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - C F Pope
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - C L Ling
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - S Patel
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - O J Billington
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - R D Gosling
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - M C Lipman
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| | - S H Gillespie
- Centre for Medical Microbiology, Department of Infection, Royal Free & University College Medical School, Pond Street, London NW3 2PF, UK 2Department of Thoracic Medicine, Royal Free Hospital NHS Trust, Pond Street, London NW3 2PF, UK
| |
Collapse
|
37
|
Chintu C, Bhat GJ, Walker AS, Mulenga V, Sinyinza F, Lishimpi K, Farrelly L, Kaganson N, Zumla A, Gillespie SH, Nunn AJ, Gibb DM. Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomised placebo-controlled trial. Lancet 2004; 364:1865-71. [PMID: 15555666 DOI: 10.1016/s0140-6736(04)17442-4] [Citation(s) in RCA: 249] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND No trials of co-trimoxazole (trimethoprim-sulfamethoxazole) prophylaxis for HIV-infected adults or children have been done in areas with high levels of bacterial resistance to this antibiotic. We aimed to assess the efficacy of daily co-trimoxazole in such an area. METHODS We did a double-blind randomised placebo-controlled trial in children aged 1-14 years with clinical features of HIV infection in Zambia. Primary outcomes were mortality and adverse events possibly related to treatment. Analysis was by intention to treat. FINDINGS In October, 2003, the data and safety monitoring committee recommended early stopping of the trial. 541 children had been randomly assigned; seven were subsequently identified as HIV negative and excluded. After median follow-up of 19 months, 74 (28%) children in the co-trimoxazole group and 112 (42%) in the placebo group had died (hazard ratio [HR] 0.57 [95% CI 0.43-0.77], p=0.0002). This benefit applied in children followed up beyond 12 months (n=320, HR 0.48 [0.27-0.84], test for heterogeneity p=0.60) and across all ages (test for heterogeneity p=0.82) and baseline CD4 counts (test for heterogeneity p=0.36). 16 (6%) children in the co-trimoxazole group had grade 3 or 4 adverse events compared with 18 (7%) in the placebo group. These events included rash (one placebo), and a neutrophil count on one occasion less than 0.5x10(9)/L (16 [6%] co-trimoxazole vs seven [3%] placebo, p=0.06). Pneumocystis carinii was identified by immunofluorescence in only one (placebo) of 73 nasopharyngeal aspirates from children with pneumonia. INTERPRETATION Our results suggest that children of all ages with clinical features of HIV infection should receive co-trimoxazole prophylaxis in resource-poor settings, irrespective of local resistance to this drug.
Collapse
Affiliation(s)
- C Chintu
- University Teaching Hospital, Lusaka, Zambia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Kerbiriou L, Ustianowski A, Johnson M, Gillespie SH, Miller RF, Lipman M. Reply. Clin Infect Dis 2004. [DOI: 10.1086/392519] [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: 11/03/2022] Open
|
39
|
Charalambous BM, Batt SL, Peek AC, Mwerinde H, Sam N, Gillespie SH. Quantitative validation of media for transportation and storage of Streptococcus pneumoniae. J Clin Microbiol 2004; 41:5551-6. [PMID: 14662939 PMCID: PMC309041 DOI: 10.1128/jcm.41.12.5551-5556.2003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The need to design effective Streptococcus pneumoniae vaccines and to monitor resistance means that it is essential to have efficient methods to determine carriage rates. Two liquid media, consisting of skim milk, glycerol, glucose, and tryptone soya broth (STGG) or skim milk, glycerol, and glucose (SGG) alone, were evaluated for their ability to maintain pneumococcal viability. Optimal recovery of S. pneumoniae was achieved when swabs were transferred to STGG medium prior to plating onto blood agar-gentamicin selective plates (22%) compared to 7% when plated out directly (P < 0.0001 by Fisher's exact test). Both STGG and SGG media are appropriate for the long-term storage of pneumococci and primary swab samples at -70 degrees C, with no decrease in viable count observed following repeated freeze-thaw cycles. Samples could be stored refrigerated for up to 3 days in either STGG or SGG medium with no significant loss of viability. Viability decreased progressively in storage at 20 to 30 degrees C, with greater losses of viability occurring at the higher temperatures. There were no significant differences in viability between isolates in the two media. STGG preserved pneumococci significantly better (about twofold) than SGG medium at 21 degrees C (P < 0.0001) and 30 degrees C (P < 0.0001). Samples can be stored for 4 and 2.5 days at 6 to 8 degrees C, 28 and 17 h at 21 degrees C, and 15 and 7 h at 30 degrees C in STGG and SGG media, respectively. For field studies undertaken in resource-limited environments, SGG medium can be prepared by using locally available materials. The quantitative data reported in this study will enable researchers to plan appropriate transport and storage protocols.
Collapse
Affiliation(s)
- B M Charalambous
- Department of Medical Microbiology, University College London, Royal Free Campus, London NW3 2PF, United Kingdom
| | | | | | | | | | | |
Collapse
|
40
|
Kerbiriou L, Ustianowski A, Johnson MA, Gillespie SH, Miller RF, Lipman MCI. Human immunodeficiency virus type 1-related pulmonary Mycobacterium xenopi infection: a need to treat? Clin Infect Dis 2003; 37:1250-4. [PMID: 14557971 DOI: 10.1086/378806] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2003] [Accepted: 06/30/2003] [Indexed: 11/03/2022] Open
Abstract
We report treatment decisions and outcomes for 20 patients who were infected with human immunodeficiency virus type 1 (HIV-1) and were receiving highly active antiretroviral therapy (HAART) who had respiratory symptoms and from whom Mycobacterium xenopi was isolated. All patients also had coexisting pulmonary pathologic conditions. The median blood T cell CD4 count was 37 cells/microL (range, 2-480 cells/microL). Fifteen of 20 patients received no antimycobacterial therapy and remain healthy after a median of approximately 4 years of follow-up, and 2 patients required treatment specifically for M. xenopi infection, both showing clinical improvement. We conclude that pulmonary M. xenopi isolation in HIV-1 patients receiving HAART does not usually require specific treatment.
Collapse
Affiliation(s)
- L Kerbiriou
- Department of Respiratory Medicine, Royal Free Hospital, London, United Kingdom
| | | | | | | | | | | |
Collapse
|
41
|
Abstract
There are now a wide range of techniques available to type Mycobacterium tuberculosis, the problem is to choose the correct technique. For large scale epidemiological studies the portability and standardization of IS6110 restriction fragment length polymorphism (RFLP) means that this remains the gold standard technique. In the next few years the internationally standard mycobacterial interspersed repetitive unit (MIRU) may come to challenge this primacy. Low copy number stains remain a problem and these can be typed by either polymorphic Guanine cytosine-rich repetitive sequence (PGRS) or MIRU-variable numbers of tandem repeat (VNTR). To confirm whether strains are part of a true cluster PGRS remains the method of choice. For local outbreaks and investigations of laboratory cross contamination where speed is of greatest importance suspect strains should be initially investigated using a PCR-based method. The superior reproducibility and discrimination of MIRU-VNTR means that these methods should be favoured. If matches are found, then further confirmation of identity can be achieved using IS6110 RFLP or PGRS if the strains prove to have a low IS6110 copy number.
Collapse
Affiliation(s)
- E Kanduma
- Clinical Laboratory, Kilimanjaro Christian Medical College, PO Box 3010, Moshi, Tanzania
| | | | | |
Collapse
|
42
|
Gillespie SH, Charalambous BM. A novel method for evaluating the antimicrobial activity of tuberculosis treatment regimens. Int J Tuberc Lung Dis 2003; 7:684-9. [PMID: 12870691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVE To evaluate the clinical response to antituberculosis chemotherapy rapidly. METHOD Sputum viable counts from a previously published clinical trial comparing a standard regimen and one containing isoniazid, rifampicin and ciprofloxacin were re-evaluated using an exponential decay model. The results were fitted to a one or two phase exponential decline. The decline in viable counts followed a curve described by a single-phase exponential decay model. From these data the time taken to reduce the viable count by 50% (vt50) was calculated to estimate the bactericidal effect of the regimens. RESULTS AND CONCLUSION This method shows promise as a means for early identification of patients who are responding poorly as a result of resistance or poor immune response and for comparing anti-tuberculosis regimens in clinical trials. The failure to show a two-phase exponential decay curve suggested that either the sputum does not contain bacteria upon which only drugs with a sterilising activity act or that they are not present in sufficient numbers to have a significant impact on the total viable count. Further studies are required to understand the physiological state of organisms being sampled in sputum.
Collapse
Affiliation(s)
- S H Gillespie
- Department of Medical Microbiology, University College London, London, United Kingdom.
| | | |
Collapse
|
43
|
Ruddy M, McHugh TD, Dale JW, Banerjee D, Maguire H, Wilson P, Drobniewski F, Butcher P, Gillespie SH. Estimation of the rate of unrecognized cross-contamination with mycobacterium tuberculosis in London microbiology laboratories. J Clin Microbiol 2002; 40:4100-4. [PMID: 12409381 PMCID: PMC139701 DOI: 10.1128/jcm.40.11.4100-4104.2002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Isolates from patients with confirmed tuberculosis from London were collected over 2.5 years between 1995 and 1997. Restriction fragment length polymorphism (RFLP) analysis was performed by the international standard technique as part of a multicenter epidemiological study. A total of 2,779 samples representing 2,500 individual patients from 56 laboratories were examined. Analysis of these samples revealed a laboratory cross-contamination rate of between 0.54%, when only presumed cases of cross-contamination were considered, and 0.93%, when presumed and possible cases were counted. Previous studies suggest an extremely wide range of laboratory cross-contamination rates of between 0.1 and 65%. These data indicate that laboratory cross-contamination has not been a common problem in routine practice in the London area, but in several incidents patients did receive full courses of therapy that were probably unnecessary.
Collapse
Affiliation(s)
- M Ruddy
- Department of Medical Microbiology, Royal Free and University College Medical School, London NW3 2PF, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Whiting GC, Evans JT, Patel S, Gillespie SH. Purification of native alpha-enolase from Streptococcus pneumoniae that binds plasminogen and is immunogenic. J Med Microbiol 2002; 51:837-843. [PMID: 12435062 DOI: 10.1099/0022-1317-51-10-837] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Many pathogenic bacteria express plasminogen receptors on their surface, which may play a role in the dissemination of organisms by binding plasminogen that, when converted to plasmin, can digest extracellular matrix proteins. A 45-kDa protein was purified from Streptococcus pneumoniae and confirmed as an alpha-enolase by its ability to catalyse the dehydration of 2-phospho-D-glycerate to phosphoenolpyruvate and by N-terminal sequencing. The activity of alpha-enolase was found in the cytoplasm and in whole cells. Activity was also demonstrated in cell wall fractions, which confirmed that alpha-enolase is a cytoplasmic antigen also expressed on the surface of S. pneumoniae. The plasminogen-binding activity of alpha-enolase was examined by Western blot, which showed that purified alpha-enolase was able to bind human plasminogen. Immunoblots of the purified 45-kDa alpha-enolase with 22 sera from patients with pneumococcal disease showed binding in 15 cases, indicating that pneumococcal enolase is immunogenic.
Collapse
Affiliation(s)
- G C Whiting
- Department of Medical Microbiology, Royal Free and University College Medical School, London NW3 2PF
| | - J T Evans
- Department of Medical Microbiology, Royal Free and University College Medical School, London NW3 2PF
| | - S Patel
- Department of Medical Microbiology, Royal Free and University College Medical School, London NW3 2PF
| | - S H Gillespie
- Department of Medical Microbiology, Royal Free and University College Medical School, London NW3 2PF
| |
Collapse
|
45
|
Maguire H, Dale JW, McHugh TD, Butcher PD, Gillespie SH, Costetsos A, Al-Ghusein H, Holland R, Dickens A, Marston L, Wilson P, Pitman R, Strachan D, Drobniewski FA, Banerjee DK. Molecular epidemiology of tuberculosis in London 1995-7 showing low rate of active transmission. Thorax 2002; 57:617-22. [PMID: 12096206 PMCID: PMC1746370 DOI: 10.1136/thorax.57.7.617] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tuberculosis notification rates for London have risen dramatically in recent years. Molecular typing of Mycobacterium tuberculosis has contributed to our understanding of the epidemiology of tuberculosis throughout the world. This study aimed to assess the degree of recent transmission of M tuberculosis in London and subpopulations of the community with high rates of recent transmission. METHODS M tuberculosis isolates from all persons from Greater London diagnosed with culture positive tuberculosis between 1 July 1995 and 31 December 1997 were genetically fingerprinted using IS6110 restriction fragment length polymorphism (RFLP) typing. A structured proforma was used during record review of cases of culture confirmed tuberculosis. Cluster analysis was performed and risk factors for clustering were examined in a univariate analysis followed by a logistic regression analysis with membership of a cluster as the outcome variable. RESULTS RFLP patterns were obtained for 2042 isolates with more than four copies of IS6110; 463 (22.7%) belonged to 169 molecular clusters, which ranged in size from two (65% of clusters) to 12 persons. The estimated rate of recent transmission was 14.4%. Young age (0-19 years) (odds ratio (OR) 2.65, 95% confidence interval (CI) 1.59 to 4.44), birth in the UK (OR 1.55, 95% CI 1.04 to 2.03), black Caribbean ethnic group (OR 2.19, 95% CI 1.15 to 4.16), alcohol dependence (OR 2.33, 95% CI 1.46 to 3.72), and streptomycin resistance (OR 1.82, 95% CI 1.15 to 2.88) were independently associated with an increased risk of clustering. CONCLUSIONS Tuberculosis in London is largely caused by reactivation or importation of infection by recent immigrants. Newly acquired infection is also common among people with recognised risk factors. Preventative interventions and early diagnosis of immigrants from areas with a high incidence of tuberculosis, together with thorough contact tracing and monitoring of treatment outcome among all cases of tuberculosis (especially in groups at higher risk of recent infection), remains most important.
Collapse
Affiliation(s)
- H Maguire
- Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre, London W2 3QR, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Gillespie SH. Mycobacterium tuberculosis Protocols. Methods in Molecular Medicine series.: T. Parish and N. G. Stoker, Eds. Humana Press, Totowa, NJ, USA. ISBN 0-89603-776-2. 403 pp. J Antimicrob Chemother 2002. [DOI: 10.1093/jac/49.1.226] [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: 11/14/2022] Open
|
47
|
Barlow RE, Gascoyne-Binzi DM, Gillespie SH, Dickens A, Qamer S, Hawkey PM. Comparison of variable number tandem repeat and IS6110-restriction fragment length polymorphism analyses for discrimination of high- and low-copy-number IS6110 Mycobacterium tuberculosis isolates. J Clin Microbiol 2001; 39:2453-7. [PMID: 11427553 PMCID: PMC88169 DOI: 10.1128/jcm.39.7.2453-2457.2001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The present study was designed to evaluate the use of variable number tandem repeat (VNTR) and IS6110-restriction fragment length polymorphism (RFLP) analyses in combination as a two-step strategy for discrimination (as measured by the Hunter-Gaston Discrimination Index [HGDI]) of both high- and low-copy-number IS6110 Mycobacterium tuberculosis isolates compared to IS6110-RFLP alone with an unselected collection of isolates. Individually, IS6110-RFLP fingerprinting produced six clusters that accounted for 69% of the low-copy-number IS6110 isolates (five clusters) and 5% of the high-copy-number IS6110 isolates (one cluster). A total of 39% of all the isolates were clustered (HGDI = 0.97). VNTR analysis generated a total of 35 different VNTR allele profile sets from 93 isolates (HGDI = 0.938). Combining IS6110-RFLP analysis with VNTR analysis reduced the overall percentage of clustered isolates to 29% (HGDI = 0.988) and discriminated a further 27% of low-copy-number isolates that would have been clustered by IS6110-RFLP alone. The use of VNTR analysis as an initial typing strategy facilitates further analysis by IS6110-RFLP, and more importantly, VNTR analysis subdivides some IS6110-RFLP-defined clusters containing low- and single-copy IS6110 isolates.
Collapse
Affiliation(s)
- R E Barlow
- The Division of Microbiology, School of Biochemistry & Molecular Biology, University of Leeds, Leeds LS2 9JT, United Kingdom
| | | | | | | | | | | |
Collapse
|
48
|
Abstract
Antibiotic resistance poses a serious threat to modern medical practice making treatment more difficult and is associated with increased mortality among patients infected with resistant organisms. There is clear evidence that acquisition of resistance is associated with a decrease in the fitness of the organisms at least in the short term. Evidence from in vitro experiments indicates that bacteria have the ability to adapt to this deficit and recover fitness on serial passage. More recent results show that identical organisms isolated from patients in outbreaks have an initial deficit but that adaptation occurs in vivo. Strategies directed towards controlling resistance must move beyond wishful thinking that supposes that these organisms will disappear merely with control of prescribing. In some cases, resistance will not disappear because there is no evolutionary disadvantage in being resistant once adaptation has taken place. It is important, therefore, that we direct our efforts towards preventing primary resistance emerging and in limiting the spread of resistant strains. Ultimately, we must look again to new drug discovery to improve our therapeutic armoury.
Collapse
Affiliation(s)
- S H Gillespie
- Royal Free and University College Medical School, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK.
| |
Collapse
|
49
|
Gillespie SH. In Vitro Assessment of the Fitness of Resistant M. tuberculosis Bacteria by Competition Assay. Methods Mol Med 2001; 48:233-236. [PMID: 21374423 DOI: 10.1385/1-59259-077-2:233] [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] [Indexed: 05/30/2023]
Abstract
Bacteria become resistant by a number of different mechanisms, and these include mutation in chromosomal genes (1), acquisition of plasmids (2), insertion of bacteriophage, transposon or insertion sequence DNA (3-5), or gene mosaicism (6). There is a dogma that bacteria that become resistant pay a significant physiological price and that if antimicrobial prescribing is controlled it will result in the eradication of resistant organisms. There are only very few studies that investigate the physiology of resistance acquisition and these do show that a physiological price is paid for this change (7, 8). Once an organism acquires resistance through mutation, acquisition of resistance genes via plasmids, transposons and bacteriophages the initial physiological defect is compensated by the antibiotic selective pressure, which balances the physiological deficit imposed by the resistant mutation or additional DNA (8, 9).
Collapse
Affiliation(s)
- S H Gillespie
- Department of Medical Microbiology, Royal Free and University College Medical School, Royal Free Campus, London, UK
| |
Collapse
|
50
|
Abstract
The pathogenesis of pneumococcal infection is a complex interplay between pneumococcal virulence determinants and the host immune response. Molecular studies have considerably advanced our knowledge and understanding of the precise structures and functions of the different determinants and their pathogenic roles. This review describes the mechanisms by which pneumococci attach, invade, evade lung defences and cause severe disease. Better understanding of the critical steps in this complex process will enable more effective clinical intervention to be developed to reduce the mortality exacted by this versatile pathogen.
Collapse
Affiliation(s)
- S H Gillespie
- Department of Medical Microbiology, Royal Free Campus, Royal Free and University College Medical School, Rowland Hill Street, London NW3 2PF
| | - I Balakrishnan
- Department of Medical Microbiology, Royal Free Campus, Royal Free and University College Medical School, Rowland Hill Street, London NW3 2PF
| |
Collapse
|