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Ju G, Liu X, Yang W, Xu N, Chen L, Zhang C, He Q, Zhu X, Ouyang D. Model-Informed Precision Dosing of Isoniazid: Parametric Population Pharmacokinetics Model Repository. Drug Des Devel Ther 2024; 18:801-818. [PMID: 38500691 PMCID: PMC10946406 DOI: 10.2147/dddt.s434919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction Isoniazid (INH) is a crucial first-line anti tuberculosis (TB) drug used in adults and children. However, various factors can alter its pharmacokinetics (PK). This article aims to establish a population pharmacokinetic (popPK) models repository of INH to facilitate clinical use. Methods A literature search was conducted until August 23, 2022, using PubMed, Embase, and Web of Science databases. We excluded published popPK studies that did not provide full model parameters or used a non-parametric method. Monte Carlo simulation works was based on RxODE. The popPK models repository was established using R. Non-compartment analysis was based on IQnca. Results Fourteen studies included in the repository, with eleven studies conducted in adults, three studies in children, one in pregnant women. Two-compartment with allometric scaling models were commonly used as structural models. NAT2 acetylator phenotype significantly affecting the apparent clearance (CL). Moreover, postmenstrual age (PMA) influenced the CL in pediatric patients. Monte Carlo simulation results showed that the geometric mean ratio (95% Confidence Interval, CI) of PK parameters in most studies were within the acceptable range (50.00-200.00%), pregnant patients showed a lower exposure. After a standard treatment strategy, there was a notable exposure reduction in the patients with the NAT2 RA or nonSA (IA/RA) phenotype, resulting in a 59.5% decrease in AUC0-24 and 83.2% decrease in Cmax (Infants), and a 49.3% reduction in AUC0-24 and 73.5% reduction in Cmax (Adults). Discussion Body weight and NAT2 acetylator phenotype are the most significant factors affecting the exposure of INH. PMA is a crucial factor in the pediatric population. Clinicians should consider these factors when implementing model-informed precision dosing of INH. The popPK model repository for INH will aid in optimizing treatment and enhancing patient outcomes.
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Affiliation(s)
- Gehang Ju
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Clinical Pharmacology, Central South University, Changsha, People’s Republic of China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
| | - Xin Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Clinical Pharmacology, Central South University, Changsha, People’s Republic of China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
| | - Wenyu Yang
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Nuo Xu
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Lulu Chen
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
- Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
| | - Chenchen Zhang
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Qingfeng He
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Xiao Zhu
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Dongsheng Ouyang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Clinical Pharmacology, Central South University, Changsha, People’s Republic of China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
- Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
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Zubair M. Clinical applications of artificial intelligence in identification and management of bacterial infection: Systematic review and meta-analysis. Saudi J Biol Sci 2024; 31:103934. [PMID: 38304541 PMCID: PMC10831261 DOI: 10.1016/j.sjbs.2024.103934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024] Open
Abstract
Pneumonia is declared a global emergency public health crisis in children less than five age and the geriatric population. Recent advancements in deep learning models could be utilized effectively for the timely and early diagnosis of pneumonia in immune-compromised patients to avoid complications. This systematic review and meta-analysis utilized PRISMA guidelines for the selection of ten articles included in this study. The literature search was done through electronic databases including PubMed, Scopus, and Google Scholar from 1st January 2016 till 1 July 2023. Overall studies included a total of 126,610 images and 1706 patients in this meta-analysis. At a 95% confidence interval, for pooled sensitivity was 0.90 (0.85-0.94) and I2 statistics 90.20 (88.56 - 91.92). The pooled specificity for deep learning models' diagnostic accuracy was 0.89 (0.86---0.92) and I2 statistics 92.72 (91.50 - 94.83). I2 statistics showed low heterogeneity across studies highlighting consistent and reliable estimates, and instilling confidence in these findings for researchers and healthcare practitioners. The study highlighted the recent deep learning models single or in combination with high accuracy, sensitivity, and specificity to ensure reliable use for bacterial pneumonia identification and differentiate from other viral, fungal pneumonia in children and adults through chest x-rays and radiographs.
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Affiliation(s)
- Mohammad Zubair
- Department of Medical Microbiology, Faculty of Medicine, University of Tabuk, Tabuk 71491, Kingdom of Saudi Arabia
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Thu NQ, Tien NTN, Yen NTH, Duong TH, Long NP, Nguyen HT. Push forward LC-MS-based therapeutic drug monitoring and pharmacometabolomics for anti-tuberculosis precision dosing and comprehensive clinical management. J Pharm Anal 2024; 14:16-38. [PMID: 38352944 PMCID: PMC10859566 DOI: 10.1016/j.jpha.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/25/2023] [Accepted: 09/18/2023] [Indexed: 02/16/2024] Open
Abstract
The spread of tuberculosis (TB), especially multidrug-resistant TB and extensively drug-resistant TB, has strongly motivated the research and development of new anti-TB drugs. New strategies to facilitate drug combinations, including pharmacokinetics-guided dose optimization and toxicology studies of first- and second-line anti-TB drugs have also been introduced and recommended. Liquid chromatography-mass spectrometry (LC-MS) has arguably become the gold standard in the analysis of both endo- and exo-genous compounds. This technique has been applied successfully not only for therapeutic drug monitoring (TDM) but also for pharmacometabolomics analysis. TDM improves the effectiveness of treatment, reduces adverse drug reactions, and the likelihood of drug resistance development in TB patients by determining dosage regimens that produce concentrations within the therapeutic target window. Based on TDM, the dose would be optimized individually to achieve favorable outcomes. Pharmacometabolomics is essential in generating and validating hypotheses regarding the metabolism of anti-TB drugs, aiding in the discovery of potential biomarkers for TB diagnostics, treatment monitoring, and outcome evaluation. This article highlighted the current progresses in TDM of anti-TB drugs based on LC-MS bioassay in the last two decades. Besides, we discussed the advantages and disadvantages of this technique in practical use. The pressing need for non-invasive sampling approaches and stability studies of anti-TB drugs was highlighted. Lastly, we provided perspectives on the prospects of combining LC-MS-based TDM and pharmacometabolomics with other advanced strategies (pharmacometrics, drug and vaccine developments, machine learning/artificial intelligence, among others) to encapsulate in an all-inclusive approach to improve treatment outcomes of TB patients.
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Affiliation(s)
- Nguyen Quang Thu
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Busan, 47392, Republic of Korea
| | - Nguyen Tran Nam Tien
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Busan, 47392, Republic of Korea
| | - Nguyen Thi Hai Yen
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Busan, 47392, Republic of Korea
| | - Thuc-Huy Duong
- Department of Chemistry, University of Education, Ho Chi Minh City, 700000, Viet Nam
| | - Nguyen Phuoc Long
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Busan, 47392, Republic of Korea
| | - Huy Truong Nguyen
- Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, 700000, Viet Nam
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Iancu A, Leb I, Prokosch HU, Rödle W. Machine learning in medication prescription: A systematic review. Int J Med Inform 2023; 180:105241. [PMID: 37939541 DOI: 10.1016/j.ijmedinf.2023.105241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 09/17/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Medication prescription is a complex process that could benefit from current research and development in machine learning through decision support systems. Particularly pediatricians are forced to prescribe medications "off-label" as children are still underrepresented in clinical studies, which leads to a high risk of an incorrect dose and adverse drug effects. METHODS PubMed, IEEE Xplore and PROSPERO were searched for relevant studies that developed and evaluated well-performing machine learning algorithms following the PRISMA statement. Quality assessment was conducted in accordance with the IJMEDI checklist. Identified studies were reviewed in detail, including the required variables for predicting the correct dose, especially of pediatric medication prescription. RESULTS The search identified 656 studies, of which 64 were reviewed in detail and 36 met the inclusion criteria. According to the IJMEDI checklist, five studies were considered to be of high quality. 19 of the 36 studies dealt with the active substance warfarin. Overall, machine learning algorithms based on decision trees or regression methods performed superior regarding their predictive power than algorithms based on neural networks, support vector machines or other methods. The use of ensemble methods like bagging or boosting generally enhanced the accuracy of the dose predictions. The required input and output variables of the algorithms were considerably heterogeneous and differ strongly among the respective substance. CONCLUSIONS By using machine learning algorithms, the prescription process could be simplified and dosing correctness could be enhanced. Despite the heterogenous results among the different substances and cases and the lack of pediatric use cases, the identified approaches and required variables can serve as an excellent starting point for further development of algorithms predicting drug doses, particularly for children. Especially the combination of physiologically-based pharmacokinetic models with machine learning algorithms represents a great opportunity to enhance the predictive power and accuracy of the developed algorithms.
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Affiliation(s)
- Alexa Iancu
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Wetterkreuz 15, 91058 Erlangen, Germany
| | - Ines Leb
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Wetterkreuz 15, 91058 Erlangen, Germany
| | - Hans-Ulrich Prokosch
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Wetterkreuz 15, 91058 Erlangen, Germany
| | - Wolfgang Rödle
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Wetterkreuz 15, 91058 Erlangen, Germany.
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Pattanaik S, Gota V, Tripathi SK, Kshirsagar NA. Therapeutic drug monitoring in India: A strength, weakness, opportunity and threats analysis. Br J Clin Pharmacol 2023; 89:3247-3261. [PMID: 37259249 DOI: 10.1111/bcp.15808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/25/2023] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
Over the last three to four decades, Therapeutic Drug Monitoring (TDM) has shaped itself as therapeutic drug management, an integral component of precision medicine. The practice of TDM is not extensive in India, despite being one of the fastest-growing economies in the world. It is currently limited to a few academic medical centres and teaching hospitals. Apart from the immunosuppressive drugs, several other therapeutic areas, such as anticancer, antifungal, antibiotic and antitubercular, have demonstrated great potential to improve patient outcomes in Indian settings. Factors such as the higher prevalence of nutritional deficiencies, tropical diseases, widespread use of alternative medicines, unalike pharmacogenomics and sparse population-specific data available on therapeutic ranges of several drugs make the population of this subcontinent unique regarding the relevance of TDM. Despite the impact of TDM in clinical science and its widespread application, TDM has failed to receive the attention it deserves in India. This review intends to bring out a strength, weakness, opportunity and threats (SWOT) analysis for TDM in India so that appropriate steps for fostering the growth of TDM could be envisioned. The need of the hour is the creation of a cooperative group including all the stakeholders, such as TDM professionals, clinicians and the government and devising a National Action Plan to strengthen TDM. Nodal TDM centres should be established, and pilot programmes should be rolled out to identify the thrust areas for TDM in the country, capacity building and creating awareness to integrate TDM into mainstream clinical medicine.
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Affiliation(s)
- Smita Pattanaik
- Clinical Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikram Gota
- Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Kharghar Navi Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | | | - Nilima A Kshirsagar
- Clinical Pharmacology, Indian Council of Medical Research, New Delhi, India
- Seth Gordhandas Sunderdas, Medical College and King Edward Memorial Hospital, Mumbai, India
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Singh UB, Ray Y, Kanswal S, Sharma HP, Aayilliath AK, Wig N, Ahuja V, Biswas A, Velpandian T. Low rifampicin levels in plasma associated with a poor clinical response in patients with abdominal TB. Int J Tuberc Lung Dis 2023; 27:787-789. [PMID: 37749829 PMCID: PMC10519389 DOI: 10.5588/ijtld.23.0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/15/2023] [Indexed: 09/27/2023] Open
Affiliation(s)
- U B Singh
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), New Delhi
| | - Y Ray
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), New Delhi, Department of Medicine, AIIMS, New Delhi
| | - S Kanswal
- Centralized Core Research Facility, AIIMS, New Delhi
| | - H P Sharma
- Centralized Core Research Facility, AIIMS, New Delhi
| | - A K Aayilliath
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), New Delhi, Department of Medicine, AIIMS, New Delhi
| | - N Wig
- Department of Medicine, AIIMS, New Delhi
| | - V Ahuja
- Department of Gastroenterology, AIIMS, New Delhi
| | - A Biswas
- Department of Medicine, AIIMS, New Delhi
| | - T Velpandian
- Department of Ocular Pharmacology & Pharmacy, AIIMS, New Delhi, India
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Chen RH, Michael T, Kuhlin J, Schön T, Stocker S, Alffenaar JWC. Is there a need to optimise pyrazinamide doses in patients with tuberculosis? A systematic review. Int J Antimicrob Agents 2023; 62:106914. [PMID: 37419292 DOI: 10.1016/j.ijantimicag.2023.106914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023]
Abstract
Pyrazinamide (PZA) is a first-line antituberculosis drug with potent sterilising activity. Variability in drug exposure may translate into suboptimal treatment responses. This systematic review, conducted according to PRISMA guidelines, aimed to evaluate the concentration-effect relationship. In vitro/in vivo studies had to contain information on the infection model, PZA dose and concentration, and microbiological outcome. Human studies had to present information on PZA dose, measures of drug exposure and maximum concentration, and microbiological response parameter or overall treatment outcome. A total of 34 studies were assessed, including in vitro (n = 2), in vivo (n = 3) and clinical studies (n = 29). Intracellular and extracellular models demonstrated a direct correlation between PZA dose of 15-50 mg/kg/day and reduction in bacterial count between 0.50-27.7 log10 CFU/mL. Consistent with this, higher PZA doses (>150 mg/kg) were associated with a greater reduction in bacterial burden in BALB/c mice models. Human pharmacokinetic studies displayed a linear positive correlation between PZA dose (i.e. 21.4-35.7 mg/kg/day) and drug exposure (AUC range 220.6-514.5 mg·h/L). Additionally, human studies confirmed a dose-effect relationship, with an increased 2-month sputum culture conversion rate at AUC/MIC targets of 8.4-11.3 with higher exposure/susceptibility ratios leading to greater efficacy. A 5-fold variability in AUC was observed at PZA dose of 25 mg/kg. A direct concentration-effect relationship and increased treatment efficacy with higher PZA exposure to susceptibility ratios was observed. Taking into account variability in drug exposure and treatment response, further studies on dose optimisation are justified.
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Affiliation(s)
- Ricky Hao Chen
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Toni Michael
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Johanna Kuhlin
- Karolinska Institutet, Department of Medicine Solna, Division of Infectious Diseases, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Schön
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden; Department of Infectious Diseases, Kalmar County Hospital, Linköping University, Kalmar, Sweden
| | - Sophie Stocker
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, The University of New South Wales, Sydney, NSW, Australia; Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia; Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia.
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Thomas TA, Lukumay S, Yu S, Rao P, Siemiątkowska A, Kagan L, Augustino D, Mejan P, Mosha R, Handler D, Petros de Guex K, Mmbaga B, Pfaeffle H, Reiss R, Peloquin CA, Vinnard C, Mduma E, Xie YL, Heysell SK. Rifampin urinary excretion to predict serum targets in children with tuberculosis: a prospective diagnostic accuracy study. Arch Dis Child 2023; 108:616-621. [PMID: 37171408 PMCID: PMC10766442 DOI: 10.1136/archdischild-2022-325250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/13/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Pharmacokinetic variability drives tuberculosis (TB) treatment outcomes but measurement of serum drug concentrations for personalised dosing is inaccessible for children in TB-endemic settings. We compared rifampin urine excretion for prediction of a serum target associated with treatment outcome. DESIGN Prospective diagnostic accuracy study. SETTING Inpatient wards and outpatient clinics, northern Tanzania. PATIENTS Children aged 4-17 years were consecutively recruited on initiation of WHO-approved treatment regimens. INTERVENTIONS Samples were collected after directly observed therapy at least 2 weeks after initiation in the intensive phase: serum at pre-dose and 1, 2 and 6 hours post-dose, later analysed by liquid chromatography-tandem mass spectrometry for calculation of rifampin total exposure or area under the concentration time curve (AUC0-24); urine at post-dose intervals of 0-4, 4-8 and 8-24 hours, with rifampin excretion amount measured onsite by spectrophotometry. MAIN OUTCOME MEASURES Receiver operating characteristic (ROC) curve for percentage of rifampin dose excreted in urine measured by spectrophotometry to predict serum rifampin AUC0-24 target of 31.7 mg*hour/L. RESULTS 89 children, 52 (58%) female, with median age of 9.1 years, had both serum and urine collection. Only 59 (66%) reached the serum AUC0-24 target, reflected by a range of urine excretion patterns. Area under the ROC curve for percentage of rifampin dose excreted in urine over 24 hours predicting serum AUC0-24 target was 69.3% (95% CI 56.7% to 81.8%), p=0.007. CONCLUSIONS Urine spectrophotometry correlated with a clinically relevant serum target for rifampin, representing a step toward personalised dosing for children in TB-endemic settings.
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Affiliation(s)
- Tania A Thomas
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Saning'o Lukumay
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Sijia Yu
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Prakruti Rao
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Anna Siemiątkowska
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
- Pharmacy, Poznań University, Poznan, Poland
| | - Leonid Kagan
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Domitila Augustino
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Paulo Mejan
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Restituta Mosha
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Deborah Handler
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kristen Petros de Guex
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Blandina Mmbaga
- Department of Pediatrics, Kilimanjaro Christian Medical College, Moshi, Tanzania, United Republic of
| | - Herman Pfaeffle
- Department of Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Robert Reiss
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Christopher Vinnard
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Estomih Mduma
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Yingda L Xie
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Scott K Heysell
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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Li J, Wen R, Li G, Cao Y, Chen Z, Chen Y, Liu C. Omicron variant of SARS-COV-2 in Shanghai: Clinical features and inactivated vaccine efficacy in 13,120 elderly patients. Int J Med Sci 2023; 20:1144-1151. [PMID: 37575277 PMCID: PMC10416717 DOI: 10.7150/ijms.84452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/27/2023] [Indexed: 08/15/2023] Open
Abstract
Background: Few reports concerning inactivated vaccine efficacy in elderly patients with Omicron infection. We aimed at demonstrating the clinical characteristics of elderly patients with mild disease and assessing the protective effect of the vaccine preliminarily. Methods: 13,120 mild patients who aged beyond 60 years old were included in this study totally, medical records were collected and analyzed. Results: Patients beyond 60 years had more chronic comorbidities, significantly lower ORF1ab and N gene CT values, and longer time of nucleic acid conversion than other age groups. Higher CT value of ORF1ab and N gene were found in older patients who received a booster dose of vaccine than in those who received two doses. The time of nucleic acid conversion was longest in unvaccinated old patients, with a decreasing trend from those who received two doses to those who received a booster doses. We also used random forest and logistic regression to screen for factors strongly associated with nucleic acid conversion and to predict the time of nucleic acid conversion. Conclusion: For mild patients with Omicron infection, patients aged>60 years had mild clinical symptoms, higher viral loads, and longer time of nucleic acid conversion, when compared with younger patients. The inactivated SARS-CoV-2 vaccine provided effective protection among adults with omicron variant infection, and the effectiveness of three doses of the vaccine was greater than that of two doses of the vaccine. Special attention should be given to elderly patients.
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Affiliation(s)
- Jingwen Li
- Department of Gastroenterology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Ru Wen
- Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Guizhu Li
- College of Mathematics and Statistics, Chongqing University, Chongqing, 400044, China
| | - Ying Cao
- Department of Intensive Care Medicine, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Zhiqiang Chen
- Department of Pediatrics, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Yaping Chen
- Department of Neurosurgery, 958 Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Chen Liu
- Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
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Tabernero P, Newton PN. Estimating the prevalence of poor-quality anti-TB medicines: a neglected risk for global TB control and resistance. BMJ Glob Health 2023; 8:e012039. [PMID: 37433693 DOI: 10.1136/bmjgh-2023-012039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/29/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVES Tuberculosis (TB) remains a major global public health problem, especially with the recent emergence of multidrug-resistant TB and extensively drug-resistant TB. There has been little consideration of the extent of substandard and falsified (SF) TB medicines as drivers of resistance. We assessed the evidence on the prevalence of SF anti-TB medicines and discussed their public health impact. MATERIALS/METHODS We searched Web of Science, Medline, Pubmed, Google Scholar, WHO, US Pharmacopeia and Medicines Regulatory Agencies websites for publications on anti-TB medicines quality up to 31 October 2021. Publications reporting on the prevalence of SF anti-TB drugs were evaluated for quantitative analysis. RESULTS Of the 530 screened publications, 162 (30.6%) were relevant to anti-TB medicines quality; of those, 65 (40.1%) described one or more TB quality surveys in a specific location or region with enough information to yield an estimate of the local prevalence of poor-quality TB medicines. 7682 samples were collected in 22 countries and of those, 1170 (15.2%) failed at least one quality test. 14.1% (879/6255) of samples failed in quality surveys, 12.5% (136/1086) in bioequivalence studies and 36.9% (87/236) in accelerated biostability studies. The most frequently assessed were rifampicin monotherapy (45 studies, 19.5%) and isoniazid monotherapy (33, 14.3%), rifampicin-isoniazid-pyrazinamide-ethambutol fixed dose combinations (28, 12.1%) and rifampicin-isoniazid (20, 8.6%). The median (IQR) number of samples collected per study was 12 (1-478). CONCLUSIONS SF, especially substandard, anti-TB medicines are present worldwide. However, TB medicine quality data are few and are therefore not generalisable that 15.2% of global anti-TB medicine supply is SF. The evidence available suggests that the surveillance of the quality of TB medicines needs to be an integral part of treatment programmes. More research is needed on the development and evaluation of rapid, affordable and accurate portable devices to empower pharmacy inspectors to screen for anti-TB medicines.
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Affiliation(s)
- Patricia Tabernero
- Public Health Unit, Faculty of Medicine, Universidad de Alcalá, Alcalá de Henares, Spain
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People's Democratic Republic
- Medicine Quality Research Group, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People's Democratic Republic
- Medicine Quality Research Group, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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11
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Liu Y, Moodley M, Pasipanodya JG, Gumbo T. Determining the Delamanid Pharmacokinetics/Pharmacodynamics Susceptibility Breakpoint Using Monte Carlo Experiments. Antimicrob Agents Chemother 2023; 67:e0140122. [PMID: 36877034 PMCID: PMC10112185 DOI: 10.1128/aac.01401-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/29/2023] [Indexed: 03/07/2023] Open
Abstract
Antimicrobial susceptibility testing, based on clinical breakpoints that incorporate pharmacokinetics/pharmacodynamics (PK/PD) and clinical outcomes, is becoming a new standard in guiding individual patient therapy as well as for drug resistance surveillance. However, for most antituberculosis drugs, breakpoints are instead defined by the epidemiological cutoff values of the MIC of phenotypically wild-type strains irrespective of PK/PD or dose. In this study, we determined the PK/PD breakpoint for delamanid by estimating the probability of target attainment for the approved dose administered at 100 mg twice daily using Monte Carlo experiments. We used the PK/PD targets (0- to 24-h area under the concentration-time curve to MIC) identified in a murine chronic tuberculosis model, hollow fiber system model of tuberculosis, early bactericidal activity studies of patients with drug-susceptible tuberculosis, and population pharmacokinetics in patients with tuberculosis. At the MIC of 0.016 mg/L, determined using Middlebrook 7H11 agar, the probability of target attainment was 100% in the 10,000 simulated subjects. The probability of target attainment fell to 25%, 40%, and 68% for PK/PD targets derived from the mouse model, the hollow fiber system model of tuberculosis, and patients, respectively, at the MIC of 0.031 mg/L. This indicates that an MIC of 0.016 mg/L is the delamanid PK/PD breakpoint for delamanid at 100 mg twice daily. Our study demonstrated that it is feasible to use PK/PD approaches to define a breakpoint for an antituberculosis drug.
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Affiliation(s)
- Yongge Liu
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, Maryland, USA
| | | | - Jotam G. Pasipanodya
- Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc., Dallas, Texas, USA
| | - Tawanda Gumbo
- Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc., Dallas, Texas, USA
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12
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Gafar F, Wasmann RE, McIlleron HM, Aarnoutse RE, Schaaf HS, Marais BJ, Agarwal D, Antwi S, Bang ND, Bekker A, Bell DJ, Chabala C, Choo L, Davies GR, Day JN, Dayal R, Denti P, Donald PR, Engidawork E, Garcia-Prats AJ, Gibb D, Graham SM, Hesseling AC, Heysell SK, Idris MI, Kabra SK, Kinikar A, Kumar AKH, Kwara A, Lodha R, Magis-Escurra C, Martinez N, Mathew BS, Mave V, Mduma E, Mlotha-Mitole R, Mpagama SG, Mukherjee A, Nataprawira HM, Peloquin CA, Pouplin T, Ramachandran G, Ranjalkar J, Roy V, Ruslami R, Shah I, Singh Y, Sturkenboom MGG, Svensson EM, Swaminathan S, Thatte U, Thee S, Thomas TA, Tikiso T, Touw DJ, Turkova A, Velpandian T, Verhagen LM, Winckler JL, Yang H, Yunivita V, Taxis K, Stevens J, Alffenaar JWC. Global estimates and determinants of antituberculosis drug pharmacokinetics in children and adolescents: a systematic review and individual patient data meta-analysis. Eur Respir J 2023; 61:2201596. [PMID: 36328357 PMCID: PMC9996834 DOI: 10.1183/13993003.01596-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Suboptimal exposure to antituberculosis (anti-TB) drugs has been associated with unfavourable treatment outcomes. We aimed to investigate estimates and determinants of first-line anti-TB drug pharmacokinetics in children and adolescents at a global level. METHODS We systematically searched MEDLINE, Embase and Web of Science (1990-2021) for pharmacokinetic studies of first-line anti-TB drugs in children and adolescents. Individual patient data were obtained from authors of eligible studies. Summary estimates of total/extrapolated area under the plasma concentration-time curve from 0 to 24 h post-dose (AUC0-24) and peak plasma concentration (C max) were assessed with random-effects models, normalised with current World Health Organization-recommended paediatric doses. Determinants of AUC0-24 and C max were assessed with linear mixed-effects models. RESULTS Of 55 eligible studies, individual patient data were available for 39 (71%), including 1628 participants from 12 countries. Geometric means of steady-state AUC0-24 were summarised for isoniazid (18.7 (95% CI 15.5-22.6) h·mg·L-1), rifampicin (34.4 (95% CI 29.4-40.3) h·mg·L-1), pyrazinamide (375.0 (95% CI 339.9-413.7) h·mg·L-1) and ethambutol (8.0 (95% CI 6.4-10.0) h·mg·L-1). Our multivariate models indicated that younger age (especially <2 years) and HIV-positive status were associated with lower AUC0-24 for all first-line anti-TB drugs, while severe malnutrition was associated with lower AUC0-24 for isoniazid and pyrazinamide. N-acetyltransferase 2 rapid acetylators had lower isoniazid AUC0-24 and slow acetylators had higher isoniazid AUC0-24 than intermediate acetylators. Determinants of C max were generally similar to those for AUC0-24. CONCLUSIONS This study provides the most comprehensive estimates of plasma exposures to first-line anti-TB drugs in children and adolescents. Key determinants of drug exposures were identified. These may be relevant for population-specific dose adjustment or individualised therapeutic drug monitoring.
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Affiliation(s)
- Fajri Gafar
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Roeland E Wasmann
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Helen M McIlleron
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Cape Town, Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - H Simon Schaaf
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead, Sydney, Australia
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
| | - Dipti Agarwal
- Ram Manohar Lohia Institute of Medical Sciences, Department of Paediatrics, Lucknow, India
| | - Sampson Antwi
- Komfo Anokye Teaching Hospital, Department of Child Health, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Department of Child Health, Kumasi, Ghana
| | | | - Adrie Bekker
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - David J Bell
- NHS Greater Glasgow and Clyde, Infectious Diseases Unit, Glasgow, UK
| | - Chishala Chabala
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospitals - Children's Hospital, Lusaka, Zambia
| | - Louise Choo
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Geraint R Davies
- Malawi Liverpool Wellcome Clinical Research Programme, Clinical Department, Blantyre, Malawi
- University of Liverpool, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- University of Oxford, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Rajeshwar Dayal
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Paolo Denti
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Peter R Donald
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ephrem Engidawork
- Addis Ababa University, College of Health Sciences, School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Addis Ababa, Ethiopia
| | - Anthony J Garcia-Prats
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Pediatrics, Madison, WI, USA
| | - Diana Gibb
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Stephen M Graham
- University of Melbourne, Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Anneke C Hesseling
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Misgana I Idris
- University of Alabama at Birmingham, Department of Biology, Birmingham, AL, USA
| | - Sushil K Kabra
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Agibothu K Hemanth Kumar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Awewura Kwara
- University of Florida, Emerging Pathogens Institute, College of Medicine, Gainesville, FL, USA
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | | | - Nilza Martinez
- Instituto Nacional de Enfermedades Respiratorias y Del Ambiente, Asunción, Paraguay
| | - Binu S Mathew
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University, Department of Medicine and Infectious Diseases, Baltimore, MD, USA
| | - Estomih Mduma
- Haydom Lutheran Hospital, Center for Global Health Research, Haydom, Tanzania
| | | | | | - Aparna Mukherjee
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Heda M Nataprawira
- Universitas Padjadjaran, Hasan Sadikin Hospital, Faculty of Medicine, Department of Child Health, Division of Paediatric Respirology, Bandung, Indonesia
| | | | - Thomas Pouplin
- Mahidol University, Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Geetha Ramachandran
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Jaya Ranjalkar
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vandana Roy
- Maulana Azad Medical College, Department of Pharmacology, New Delhi, India
| | - Rovina Ruslami
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Ira Shah
- Bai Jerbai Wadia Hospital for Children, Department of Pediatric Infectious Diseases, Pediatric TB Clinic, Mumbai, India
| | - Yatish Singh
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Marieke G G Sturkenboom
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Uppsala University, Department of Pharmacy, Uppsala, Sweden
| | - Soumya Swaminathan
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- World Health Organization, Public Health Division, Geneva, Switzerland
| | - Urmila Thatte
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Department of Clinical Pharmacology, Mumbai, India
| | - Stephanie Thee
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Berlin, Germany
| | - Tania A Thomas
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Tjokosela Tikiso
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Anna Turkova
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Thirumurthy Velpandian
- All India Institute of Medical Sciences, Ocular Pharmacology and Pharmacy Division, Dr R.P. Centre, New Delhi, India
| | - Lilly M Verhagen
- Radboud University Medical Center, Radboud Center for Infectious Diseases, Laboratory of Medical Immunology, Section of Pediatric Infectious Diseases, Nijmegen, The Netherlands
- Radboud University Medical Center, Amalia Children's Hospital, Department of Paediatric Infectious Diseases and Immunology, Nijmegen, The Netherlands
- Stellenbosch University, Family Centre for Research with UBUNTU, Department of Paediatrics and Child Health, Cape Town, South Africa
| | - Jana L Winckler
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Hongmei Yang
- University of Rochester, School of Medicine and Dentistry, Department of Biostatistics and Computational Biology, Rochester, NY, USA
| | - Vycke Yunivita
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Jasper Stevens
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- Both authors contributed equally and shared senior authorship
| | - Jan-Willem C Alffenaar
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Both authors contributed equally and shared senior authorship
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13
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Zhang H, He Y, Davies Forsman L, Paues J, Werngren J, Niward K, Schön T, Bruchfeld J, Alffenaar JW, Hu Y. Population pharmacokinetics and dose evaluations of linezolid in the treatment of multidrug-resistant tuberculosis. Front Pharmacol 2023; 13:1032674. [PMID: 36699070 PMCID: PMC9868619 DOI: 10.3389/fphar.2022.1032674] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023] Open
Abstract
Background: The pharmacokinetic/pharmacodynamics (PK/PD) target derived from the hollow-fiber system model for linezolid for treatment of the multidrug-resistant tuberculosis (MDR-TB) requires clinical validation. Therefore, this study aimed to develop a population PK model for linezolid when administered as part of a standardized treatment regimen, to identify the PK/PD threshold associated with successful treatment outcomes and to evaluate currently recommended linezolid doses. Method: This prospective multi-center cohort study of participants with laboratory-confirmed MDR-TB was conducted in five TB designated hospitals. The population PK model for linezolid was built using nonlinear mixed-effects modeling using data from 168 participants. Boosted classification and regression tree analyses (CART) were used to identify the ratio of 0- to 24-h area under the concentration-time curve (AUC0-24h) to the minimal inhibitory concentration (MIC) threshold using the BACTEC MGIT 960 method associated with successful treatment outcome and validated in multivariate analysis using data from a different and prospective cohort of 159 participants with MDR-TB. Furthermore, based on the identified thresholds, the recommended doses were evaluated by the probability of target attainment (PTA) analysis. Result: Linezolid plasma concentrations (1008 samples) from 168 subjects treated with linezolid, were best described by a 2-compartment model with first-order absorption and elimination. An AUC0-24h/MIC > 125 was identified as a threshold for successful treatment outcome. Median time to sputum culture conversion between the group with AUC0-24h/MIC above and below 125 was 2 versus 24 months; adjusted hazard ratio (aHR), 21.7; 95% confidence interval (CI), (6.4, 72.8). The boosted CART-derived threshold and its relevance to the final treatment outcome was comparable to the previously suggested target of AUC0-24h/MIC (119) using MGIT MICs in a hollow fiber infection model. Based on the threshold from the present study, at a standard linezolid dose of 600 mg daily, PTA was simulated to achieve 100% at MGIT MICs of ≤ .25 mg which included the majority (81.1%) of isolates in the study. Conclusion: We validated an AUC0-24h/MIC threshold which may serve as a target for dose adjustment to improve efficacy of linezolid in a bedaquiline-containing treatment. Linezolid exposures with the WHO-recommended dose (600 mg daily) was sufficient for all the M. tb isolates with MIC ≤ .25 mg/L.
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Affiliation(s)
- Haoyue Zhang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Yuying He
- Institute of Tuberculosis Control, Guizhou Provincial Center for Disease Control and Prevention, Guiyang, China
| | - Lina Davies Forsman
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden,Department of Medicine, Division of Infectious Diseases, Karolinska Institute, Stockholm, Sweden
| | - Jakob Paues
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden
| | - Jim Werngren
- Department of Microbiology, The Public Health Agency of Sweden, Stockholm, Sweden
| | - Katarina Niward
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden
| | - Thomas Schön
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden,Department of Infectious Diseases, Kalmar County Hospital, Linköping University, Kalmar, Sweden
| | - Judith Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden,Department of Medicine, Division of Infectious Diseases, Karolinska Institute, Stockholm, Sweden
| | - Jan-Willem Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia,Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia
| | - Yi Hu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China,*Correspondence: Yi Hu,
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14
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Solans BP, Béranger A, Radtke K, Mohamed A, Mirzayev F, Gegia M, Linh NN, Schumacher SG, Nahid P, Savic RM. Effectiveness and pharmacokinetic exposures of first-line drugs used to treat drug-susceptible tuberculosis in children: a systematic review and meta-analysis. Clin Infect Dis 2023; 76:1658-1670fc. [PMID: 36609692 PMCID: PMC10156125 DOI: 10.1093/cid/ciac973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/17/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Optimal doses of first line drugs for drug-susceptible tuberculosis (DS-TB) treatment in children and young adolescents remain uncertain. We aimed to determine if children treated using WHO-recommended or higher doses of first-line drugs achieve successful outcomes and sufficient pharmacokinetic exposures. METHODS Titles, abstracts, and full-text articles were screened. We searched Pubmed, EMBASE, CENTRAL, and trial registries from 2010 to 2021. We included studies in children <18 years, being treated for DS-TB with rifampicin, pyrazinamide, isoniazid, and ethambutol. Outcomes were treatment success rates and drug exposures. The protocol for the systematic review was preregistered in PROSPERO, CRD42021274222. RESULTS Of 304 studies identified, 46 studies were eligible for full-text review and 12 and 18 articles were included for the efficacy and pharmacokinetic analysis, respectively. Of 1,830 children included in the efficacy analysis, 82% had favourable outcomes (range 25%-95%). At WHO-recommended doses, exposures to rifampicin, pyrazinamide, and ethambutol were lower in children as compared to adults. Children ≤6 years have 35% lower AUC than older children (14.4 (9.9-18.8) vs 22.0 (13.8-30.1) μg.h/mL) and children with HIV (CWHIV) had 35% lower rifampicin AUC than HIV negative children (17.3 (11.4-23.2) vs 26.5 (21.3-31.7) μg.h/mL). Heterogeneity and small sample sizes were major limitations. CONCLUSION There is large variability in outcomes with an average 82% favourable outcomes. Drug exposures are lower in children than in adults. Younger children and CWHIV are underexposed to rifampicin. Standardization of pharmacokinetic paediatric studies and individual patient data analysis with safety assessment are needed to inform optimal dosing.
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Affiliation(s)
- Belén P Solans
- University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America.,UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, United States of America
| | - Agathe Béranger
- University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America.,UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, United States of America
| | - Kendra Radtke
- University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America.,UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, United States of America
| | - Ali Mohamed
- University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America.,UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, United States of America
| | - Fuad Mirzayev
- Global Tuberculosis Programme (GTB), World Health Organization, Geneva, Switzerland
| | - Medea Gegia
- Global Tuberculosis Programme (GTB), World Health Organization, Geneva, Switzerland
| | - Nguyen Nhat Linh
- Global Tuberculosis Programme (GTB), World Health Organization, Geneva, Switzerland
| | - Samuel G Schumacher
- Global Tuberculosis Programme (GTB), World Health Organization, Geneva, Switzerland
| | - Payam Nahid
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, United States of America.,School of Medicine, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Radojka M Savic
- University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America.,UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, United States of America
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15
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Deshpande D, Srivastava S, Pasipanodya JG, Gumbo T. Minocycline intra-bacterial pharmacokinetic hysteresis as a basis for pharmacologic memory and a backbone for once-a-week pan-tuberculosis therapy. Front Pharmacol 2022; 13:1024608. [PMID: 36330086 PMCID: PMC9622937 DOI: 10.3389/fphar.2022.1024608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/30/2022] [Indexed: 11/24/2022] Open
Abstract
Background: There is need for shorter duration regimens for the treatment of tuberculosis, that can treat patients regardless of multidrug resistance status (pan-tuberculosis). Methods: We combined minocycline with tedizolid, moxifloxacin, and rifampin, in the hollow fiber system model of tuberculosis and mimicked each drugs’ intrapulmonary pharmacokinetics for 28 days. Minocycline-tedizolid was administered either as a once-a-week or a daily regimen. In order to explore a possible explanation for effectiveness of the once-a-week regimen, we measured systemic and intra-bacterial minocycline pharmacokinetics. Standard daily therapy (rifampin, isoniazid, pyrazinamide) was the comparator. We then calculated γf or kill slopes for each regimen and ranked the regimens by time-to-extinction predicted in patients. Results: The steepest γf and shortest time-to-extinction of entire bacterial population was with daily minocycline-rifampin combination. There was no difference in γf between the minocycline-tedizolid once-a-week versus the daily therapy (p = 0.85). Standard therapy was predicted to cure 88% of patients, while minocycline-rifampin would cure 98% of patients. Minocycline concentrations fell below minimum inhibitory concentration after 2 days of once-weekly dosing schedule. The shape of minocycline intra-bacterial concentration-time curve differed from the extracellular pharmacokinetic system and lagged by several days, consistent with system hysteresis. Hysteresis explained the persistent microbial killing after hollow fiber system model of tuberculosis concentrations dropped below the minimum inhibitory concentration. Conclusion: Minocycline could form a backbone of a shorter duration once-a-week pan-tuberculosis regimen. We propose a new concept of post-antibiotic microbial killing, distinct from post-antibiotic effect. We propose system hysteresis as the basis for the novel concept of pharmacologic memory, which allows intermittent dosing.
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Affiliation(s)
| | - Shashikant Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | | | - Tawanda Gumbo
- Quantitative Preclinical and Clinical Sciences Department, Praedicare Inc, Dallas, TX, United States
- Hollow Fiber System and Experimental Therapeutics Laboratories, Praedicare Inc., Dallas, TX, United States
- *Correspondence: Tawanda Gumbo,
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16
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Phaisal W, Jantarabenjakul W, Wacharachaisurapol N, Tawan M, Puthanakit T, Wittayalertpanya S, Chariyavilaskul P. Pharmacokinetics of isoniazid and rifapentine in young paediatric patients with latent tuberculosis infection. Int J Infect Dis 2022; 122:725-732. [PMID: 35868608 DOI: 10.1016/j.ijid.2022.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES This study investigated the steady-state pharmacokinetic profiles of 3-month weekly rifapentine plus isoniazid (3HP) in children with latent tuberculosis infection (LTBI). Factors including tablet integrity, food, and pharmacogenetics were also assessed. METHODS During the 3HP treatment, blood and urine samples were collected on week 4. Isoniazid and rifapentine levels were measured using a high-performance liquid chromatography technique. Genetic variation of arylamine N-acetyltransferase 2 (NAT2) and arylacetamide deacetylase (AADAC) were assessed by the MassARRAY®. Safety and clinical outcomes at week 48 were monitored. RESULTS Twelve LTBI children [age 3.8 (range 2.1-4.9 years old)] completed the treatment [isoniazid and rifapentine dose 25.0 (range 21.7-26.8) and 25.7 (range 20.7-32.1) mg/kg, respectively]. No serious adverse events or active tuberculosis occurred. Tablet integrity was associated with decreased area under the concentration-time curve (91 vs 73 mg.hr/L, p = 0.026) and increased apparent oral clearance of isoniazid (0.27 vs 0.32 L/hr/kg, p = 0.019) and decreased rifapentine's renal clearance (CLR, 0.005 vs 0.003 L/hr, p = 0.014). Food was associated with increased CLR of isoniazid (3.45 vs 8.95 L/hr, p = 0.006) but not rifapentine. Variability in NAT2 and AADAC did not affect the pharmacokinetics of both drugs. CONCLUSIONS There is high variability in the pharmacokinetic profiles of isoniazid and rifapentine in young LTBI children. The variability was partly influenced by tablet integrity and food, but not pharmacogenetics. Further study in a larger cohort is warranted to display the relationship of these factors to treatment outcomes.
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Affiliation(s)
- Weeraya Phaisal
- Interdisciplinary Program in Biomedical Sciences, Graduate School, Chulalongkorn University, Bangkok, Thailand; Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Watsamon Jantarabenjakul
- Center of Excellence for Paediatric Infectious Diseases and Vaccines, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Thai Red Cross Emerging Infectious Diseases Clinical Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Division of Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Noppadol Wacharachaisurapol
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence for Paediatric Infectious Diseases and Vaccines, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Monta Tawan
- Center of Excellence for Paediatric Infectious Diseases and Vaccines, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Center of Excellence for Paediatric Infectious Diseases and Vaccines, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Thai Red Cross Emerging Infectious Diseases Clinical Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Division of Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supeecha Wittayalertpanya
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pajaree Chariyavilaskul
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Lopez-Varela E, Abulfathi AA, Strydom N, Goussard P, van Wyk AC, Demers AM, Deventer AV, Garcia-Prats AJ, van der Merwe J, Zimmerman M, Carter CL, Janson J, Morrison J, Reuter H, Decloedt EH, Seddon JA, Svensson EM, Warren R, Savic RM, Dartois V, Hesseling AC. Drug concentration at the site of disease in children with pulmonary tuberculosis. J Antimicrob Chemother 2022; 77:1710-1719. [PMID: 35468189 PMCID: PMC9155609 DOI: 10.1093/jac/dkac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Current TB treatment for children is not optimized to provide adequate drug levels in TB lesions. Dose optimization of first-line antituberculosis drugs to increase exposure at the site of disease could facilitate more optimal treatment and future treatment-shortening strategies across the disease spectrum in children with pulmonary TB. OBJECTIVES To determine the concentrations of first-line antituberculosis drugs at the site of disease in children with intrathoracic TB. METHODS We quantified drug concentrations in tissue samples from 13 children, median age 8.6 months, with complicated forms of pulmonary TB requiring bronchoscopy or transthoracic surgical lymph node decompression in a tertiary hospital in Cape Town, South Africa. Pharmacokinetic models were used to describe drug penetration characteristics and to simulate concentration profiles for bronchoalveolar lavage, homogenized lymph nodes, and cellular and necrotic lymph node lesions. RESULTS Isoniazid, rifampicin and pyrazinamide showed lower penetration in most lymph node areas compared with plasma, while ethambutol accumulated in tissue. None of the drugs studied was able to reach target concentration in necrotic lesions. CONCLUSIONS Despite similar penetration characteristics compared with adults, low plasma exposures in children led to low site of disease exposures for all drugs except for isoniazid.
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Affiliation(s)
- Elisa Lopez-Varela
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universidad de Barcelona, Barcelona, Spain
- Corresponding author: E-mail:
| | - Ahmed A. Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, USA
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, 94158, USA
| | - Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Abraham C. van Wyk
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anne Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Service de microbiologie, Département clinique de médecine de laboratoire, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Anneen Van Deventer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Johannes van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Matthew Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, New Jersey, USA, and Department of Medical Sciences, Hackensack School of Medicine, Nutley, New Jersey, USA
| | - Claire L. Carter
- Center for Discovery and Innovation, Hackensack Meridian Health, New Jersey, USA, and Department of Medical Sciences, Hackensack School of Medicine, Nutley, New Jersey, USA
- Department of Pathology, Hackensack School of Medicine, Nutley, New Jersey 07110, USA
| | - Jacques Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Julie Morrison
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helmuth Reuter
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric H. Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Elin M. Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research/South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, 94158, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, New Jersey, USA, and Department of Medical Sciences, Hackensack School of Medicine, Nutley, New Jersey, USA
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Vonasek BJ, Radtke KK, Vaz P, Buck WC, Chabala C, McCollum ED, Marcy O, Fitzgerald E, Kondwani A, Garcia-Prats AJ. Tuberculosis in children with severe acute malnutrition. Expert Rev Respir Med 2022; 16:273-284. [PMID: 35175880 PMCID: PMC9280657 DOI: 10.1080/17476348.2022.2043747] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION With growing attention globally to the childhood tuberculosis epidemic after decades of neglect, and with the burden of severe acute malnutrition (SAM) remaining unacceptably high worldwide, the collision of these two diseases is an important focus for improving child health. AREAS COVERED This review describes the clinical and public health implications of the interplay between tuberculosis and SAM, particularly for children under the age of five, and identifies priority areas for improved programmatic implementation and future research. We reviewed the literature on PubMed and other evidence known to the authors published until August 2021 relevant to this topic. EXPERT OPINION To achieve the World Health Organization's goal of eliminating deaths from childhood tuberculosis and to improve the abysmal outcomes for children with SAM, further research is needed to 1) better understand the epidemiologic connections between child tuberculosis and SAM, 2) improve case finding of tuberculosis in children with SAM, 3) assess unique treatment considerations for tuberculosis when children also have SAM, and 4) ensure tuberculosis and SAM are strongly addressed in decentralized, integrated models of providing primary healthcare to children.
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Affiliation(s)
- Bryan J Vonasek
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA,Corresponding Author: Bryan Vonasek, , University of Wisconsin School of Medicine & Public Health, Department of Pediatrics, 600 Highland Ave, Madison, WI, USA 53792-4108, Phone: +1-763-333-8071, Fax: +1-608-265-9243
| | - Kendra K Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Paula Vaz
- Fundação Ariel Glaser, Maputo, Mozambique
| | - W Chris Buck
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Chishala Chabala
- Children’s Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Olivier Marcy
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux, France
| | - Elizabeth Fitzgerald
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alexander Kondwani
- Centre of Excellence for Nutrition, North West University, Potchefstroom, South Africa
| | - Anthony J Garcia-Prats
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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19
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Ruiz-Bedoya CA, Mota F, Tucker EW, Mahmud FJ, Reyes-Mantilla MI, Erice C, Bahr M, Flavahan K, De Jesus P, Kim J, Foss CA, Peloquin CA, Hammoud DA, Ordonez AA, Pardo CA, Jain SK. High-dose rifampin improves bactericidal activity without increased intracerebral inflammation in animal models of tuberculous meningitis. J Clin Invest 2022; 132:155851. [PMID: 35085105 PMCID: PMC8920328 DOI: 10.1172/jci155851] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/26/2022] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis (TB meningitis) is the most severe form of tuberculosis (TB), requiring 12 months of multidrug treatment for cure, and is associated with high morbidity and mortality. High-dose rifampin (35 mg/kg/d) is safe and improves the bactericidal activity of the standard-dose (10 mg/kg/d) rifampin-containing TB regimen in pulmonary TB. However, there are conflicting clinical data regarding its benefit for TB meningitis, where outcomes may also be associated with intracerebral inflammation. We conducted cross-species studies in mice and rabbits, demonstrating that an intensified high-dose rifampin-containing regimen has significantly improved bactericidal activity for TB meningitis over the first-line, standard-dose rifampin regimen, without an increase in intracerebral inflammation. Positron emission tomography in live animals demonstrated spatially compartmentalized, lesion-specific pathology, with postmortem analyses showing discordant brain tissue and cerebrospinal fluid rifampin levels and inflammatory markers. Longitudinal multimodal imaging in the same cohort of animals during TB treatment as well as imaging studies in two cohorts of TB patients demonstrated that spatiotemporal changes in localized blood-brain barrier disruption in TB meningitis are an important driver of rifampin brain exposure. These data provide unique insights into the mechanisms underlying high-dose rifampin in TB meningitis with important implications for developing new antibiotic treatments for infections.
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Affiliation(s)
- Camilo A Ruiz-Bedoya
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Filipa Mota
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Elizabeth W Tucker
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Farina J Mahmud
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Maria I Reyes-Mantilla
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Clara Erice
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Melissa Bahr
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Kelly Flavahan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Patricia De Jesus
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - John Kim
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Catherine A Foss
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, University of Florida College of Pharmacy, Gainesville, United States of America
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, NIH, Bethesda, United States of America
| | - Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, United States of America
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20
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Ruslami R, Gafar F, Yunivita V, Parwati I, Ganiem AR, Aarnoutse RE, Wilffert B, Alffenaar JWC, Nataprawira HM. Pharmacokinetics and safety/tolerability of isoniazid, rifampicin and pyrazinamide in children and adolescents treated for tuberculous meningitis. Arch Dis Child 2022; 107:70-77. [PMID: 34183327 PMCID: PMC8685623 DOI: 10.1136/archdischild-2020-321426] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the pharmacokinetics and safety/tolerability of isoniazid, rifampicin and pyrazinamide in children and adolescents with tuberculous meningitis (TBM). DESIGN Prospective observational pharmacokinetic study with an exploratory pharmacokinetic/pharmacodynamic analysis. SETTING Hasan Sadikin Hospital, Bandung, Indonesia. PATIENTS Individuals aged 0-18 years clinically diagnosed with TBM and receiving first-line anti-tuberculosis drug dosages according to revised WHO-recommended treatment guidelines. INTERVENTIONS Plasma and cerebrospinal fluid (CSF) concentrations of isoniazid, rifampicin and pyrazinamide were assessed on days 2 and 10 of treatment. MAIN OUTCOME MEASURES Plasma exposures during the daily dosing interval (AUC0-24), peak plasma concentrations (Cmax) and CSF concentrations. RESULTS Among 20 eligible patients, geometric mean AUC0-24 of isoniazid, rifampicin and pyrazinamide was 18.5, 66.9 and 315.5 hour∙mg/L on day 2; and 14.5, 71.8 and 328.4 hour∙mg/L on day 10, respectively. Large interindividual variabilities were observed in AUC0-24 and Cmax of all drugs. All patients had suboptimal rifampicin AUC0-24 for TBM treatment indication and very low rifampicin CSF concentrations. Four patients developed grade 2-3 drug-induced liver injury (DILI) within the first 4 weeks of treatment, in whom anti-tuberculosis drugs were temporarily stopped, and no DILI recurred after reintroduction of rifampicin and isoniazid. AUC0-24 of isoniazid, rifampicin and pyrazinamide along with Cmax of isoniazid and pyrazinamide on day 10 were higher in patients who developed DILI than those without DILI (p<0.05). CONCLUSION Higher rifampicin doses are strongly warranted in treatment of children and adolescents with TBM. The association between higher plasma concentrations of isoniazid, rifampicin and pyrazinamide and the development of DILI needs confirmatory studies.
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Affiliation(s)
- Rovina Ruslami
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Fajri Gafar
- Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Vycke Yunivita
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Ida Parwati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Ahmad R Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bob Wilffert
- Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands,Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia,Westmead Hospital, Sydney, New South Wales, Australia
| | - Heda M Nataprawira
- Division of Pediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
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21
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Beraldi-Magalhaes F, Parker SL, Sanches C, Sousa Garcia L, Souza Carvalho BK, Fachi MM, de Liz MV, Pontarolo R, Lipman J, Cordeiro-Santos M, Roberts JA. Is Dosing of Ethambutol as Part of a Fixed-Dose Combination Product Optimal for Mechanically Ventilated ICU Patients with Tuberculosis? A Population Pharmacokinetic Study. Antibiotics (Basel) 2021; 10:antibiotics10121559. [PMID: 34943771 PMCID: PMC8698281 DOI: 10.3390/antibiotics10121559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) patients admitted to intensive care units (ICU) have high mortality rates. It is uncertain whether the pharmacokinetics of first-line TB drugs in ICU patients are different from outpatients. This study aims to compare the pharmacokinetics of oral ethambutol in TB patients in ICU versus TB outpatients and to determine whether contemporary dosing regimens achieve therapeutic exposures. METHODS A prospective population pharmacokinetic study of ethambutol was performed in Amazonas State, Brazil. Probability of target attainment was determined using AUC/MIC > 11.9 and Cmax/MIC > 0.48 values. Optimized dosing regimens were simulated at steady state. RESULTS Ten ICU patients and 20 outpatients were recruited. Ethambutol pharmacokinetics were best described using a two-compartment model with first-order oral absorption. Neither ICU patients nor outpatients consistently achieved optimal ethambutol exposures. The absorption rate for ethambutol was 2-times higher in ICU patients (p < 0.05). Mean bioavailability for ICU patients was >5-times higher than outpatients (p < 0.0001). Clearance and volume of distribution were 93% (p < 0.0001) and 53% (p = 0.002) lower in ICU patients, respectively. CONCLUSIONS ICU patients displayed significantly different pharmacokinetics for an oral fixed-dose combination administration of ethambutol compared to outpatients, and neither patient group consistently achieved pre-defined therapeutic exposures.
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Affiliation(s)
- Francisco Beraldi-Magalhaes
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus 69040-000, Brazil; (L.S.G.); (B.K.S.C.); (M.C.-S.)
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
- Secretaria de Estado da Saúde do Paraná, Curitiba 80010-130, Brazil
- School of Medicine, Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
- Correspondence:
| | - Suzanne L. Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.L.P.); (J.L.); (J.A.R.)
| | - Cristina Sanches
- Department of Pharmacy, Universidade Federal de São João del-Rei, Divinopolis 35501-296, Brazil;
| | - Leandro Sousa Garcia
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus 69040-000, Brazil; (L.S.G.); (B.K.S.C.); (M.C.-S.)
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Brenda Karoline Souza Carvalho
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus 69040-000, Brazil; (L.S.G.); (B.K.S.C.); (M.C.-S.)
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Mariana Millan Fachi
- Department of Pharmacy, Universidade Federal do Paraná, Curitiba 80210-170, Brazil; (M.M.F.); (R.P.)
| | - Marcus Vinicius de Liz
- Department of Chemistry and Biology, Universidade Federal Tecnológica do Paraná, Curitiba 81280-340, Brazil;
| | - Roberto Pontarolo
- Department of Pharmacy, Universidade Federal do Paraná, Curitiba 80210-170, Brazil; (M.M.F.); (R.P.)
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.L.P.); (J.L.); (J.A.R.)
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nimes, France
| | - Marcelo Cordeiro-Santos
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus 69040-000, Brazil; (L.S.G.); (B.K.S.C.); (M.C.-S.)
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
- School of Medicine, Universidade Nilton Lins, Manaus 69058-040, Brazil
| | - Jason A. Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.L.P.); (J.L.); (J.A.R.)
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nimes, France
- Department of Pharmacy, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
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22
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Gordon O, Lee DE, Liu B, Langevin B, Ordonez AA, Dikeman DA, Shafiq B, Thompson JM, Sponseller PD, Flavahan K, Lodge MA, Rowe SP, Dannals RF, Ruiz-Bedoya CA, Read TD, Peloquin CA, Archer NK, Miller LS, Davis KM, Gobburu JVS, Jain SK. Dynamic PET-facilitated modeling and high-dose rifampin regimens for Staphylococcus aureus orthopedic implant-associated infections. Sci Transl Med 2021; 13:eabl6851. [PMID: 34851697 PMCID: PMC8693472 DOI: 10.1126/scitranslmed.abl6851] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Staphylococcus aureus is a major human pathogen causing serious implant–associated infections. Combination treatment with rifampin (10 to 15 mg/kg per day), which has dose-dependent activity, is recommended to treat S. aureus orthopedic implant–associated infections. Rifampin, however, has limited bone penetration. Here, dynamic 11C-rifampin positron emission tomography (PET) performed in prospectively enrolled patients with confirmed S. aureus bone infection (n = 3) or without orthopedic infection (n = 12) demonstrated bone/plasma area under the concentration-time curve ratio of 0.14 (interquartile range, 0.09 to 0.19), exposures lower than previously thought. PET-based pharmacokinetic modeling predicted rifampin concentration-time profiles in bone and facilitated studies in a mouse model of S. aureus orthopedic implant infection. Administration of high-dose rifampin (human equipotent to 35 mg/kg per day) substantially increased bone concentrations (2 mg/liter versus <0.2 mg/liter with standard dosing) in mice and achieved higher bacterial killing and biofilm disruption. Treatment for 4 weeks with high-dose rifampin and vancomycin was noninferior to the recommended 6-week treatment of standard-dose rifampin with vancomycin in mice (risk difference, −6.7% favoring high-dose rifampin regimen). High-dose rifampin treatment ameliorated antimicrobial resistance (0% versus 38%; P = 0.04) and mitigated adverse bone remodeling (P < 0.01). Last, whole-genome sequencing demonstrated that administration of high-dose rifampin in mice reduced selection of bacterial mutations conferring rifampin resistance (rpoB) and mutations in genes potentially linked to persistence. These data suggest that administration of high-dose rifampin is necessary to achieve optimal bone concentrations, which could shorten and improve treatments for S. aureus orthopedic implant infections.
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Affiliation(s)
- Oren Gordon
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Donald E. Lee
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Bessie Liu
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Brooke Langevin
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Alvaro A. Ordonez
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dustin A. Dikeman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - John M. Thompson
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Paul D. Sponseller
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kelly Flavahan
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martin A. Lodge
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Steven P. Rowe
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert F. Dannals
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Camilo A. Ruiz-Bedoya
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Timothy D. Read
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
| | - Nathan K. Archer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lloyd S. Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Immunology, Janssen Research and Development, Spring House, PA 19477, USA
| | - Kimberly M. Davis
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Jogarao V. S. Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Sanjay K. Jain
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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23
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Srivastava S, Gumbo T, Thomas T. Repurposing Cefazolin-Avibactam for the Treatment of Drug Resistant Mycobacterium tuberculosis. Front Pharmacol 2021; 12:776969. [PMID: 34744753 PMCID: PMC8569112 DOI: 10.3389/fphar.2021.776969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background: While tuberculosis (TB) is curable and preventable, the most effective first-line antibiotics cannot kill multi-drug resistant (MDR) Mycobacterium tuberculosis (Mtb). Therefore, effective drugs are needed to combat MDR-TB, especially in children. Our objective was to repurpose cefazolin for MDR-TB treatment in children using principles of pharmacokinetic/pharmacodynamics (PK/PD). Methods: Cefazolin minimum inhibitory concentration (MIC) was identified in 17 clinical Mtb strains, with and without combination of the β-lactamase inhibitor, avibactam. Next, dose-ranging studies were performed using the intracellular hollow fiber model of TB (HFS-TB) to identify the optimal cefazolin exposure. Monte Carlo experiments were then performed in 10,000 children for optimal dose identification based on cumulative fraction of response (CFR) and Mtb susceptibility breakpoint in three age-groups. Results: Avibactam reduced the cefazolin MICs by five tube dilutions. Cefazolin-avibactam demonstrated maximal kill of 4.85 log10 CFU/mL in the intracellular HFS-TB over 28 days. The % time above MIC associated with maximal effect (EC80) was 46.76% (95% confidence interval: 43.04–50.49%) of dosing interval. For 100 mg/kg once or twice daily, the CFR was 8.46 and 61.39% in children <3 years with disseminated TB, 9.70 and 84.07% for 3–5 years-old children, and 17.20 and 76.13% for 12–15 years-old children. The PK/PD-derived susceptibility breakpoint was dose dependent at 1–2 mg/L. Conclusion: Cefazolin-avibactam combination demonstrates efficacy against both drug susceptible and MDR-TB clinical strains in the HFS-TB and could potentially be used to treat children with tuberculosis. Clinical studies are warranted to validate our findings.
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Affiliation(s)
- Shashikant Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Centre, Tyler, TX, United States.,Department of Immunology, UT Southwestern Medical Center, Dallas, TX, United States.,Department of Pharmacy Practice, Texas Tech University Health Science Center, Dallas, TX, United States
| | - Tawanda Gumbo
- Praedicare Laboratories and Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc., Dallas, TX, United States
| | - Tania Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
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24
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Pasipanodya JG, Gumbo T. The Relationship Between Drug Concentration in Tuberculosis Lesions, Epithelial Lining Fluid, and Clinical Outcomes. Clin Infect Dis 2021; 73:e3374-e3376. [PMID: 32857152 DOI: 10.1093/cid/ciaa1271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Tawanda Gumbo
- Praedicare Inc., Dallas, Texas, USA.,Department of Medicine, University of Cape Town, Observatory, South Africa
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25
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McCallum AD, Pertinez HE, Else LJ, Dilly-Penchala S, Chirambo AP, Sheha I, Chasweka M, Chitani A, Malamba RD, Meghji JZ, Gordon SB, Davies GR, Khoo SH, Sloan DJ, Mwandumba HC. Intrapulmonary Pharmacokinetics of First-line Anti-tuberculosis Drugs in Malawian Patients With Tuberculosis. Clin Infect Dis 2021; 73:e3365-e3373. [PMID: 32856694 PMCID: PMC8563277 DOI: 10.1093/cid/ciaa1265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Further work is required to understand the intrapulmonary pharmacokinetics of first-line anti-tuberculosis drugs. This study aimed to describe the plasma and intrapulmonary pharmacokinetics of rifampicin, isoniazid, pyrazinamide, and ethambutol, and explore relationships with clinical treatment outcomes in patients with pulmonary tuberculosis. METHODS Malawian adults with a first presentation of microbiologically confirmed pulmonary tuberculosis received standard 6-month first-line therapy. Plasma and intrapulmonary samples were collected 8 and 16 weeks into treatment and drug concentrations measured in plasma, lung/airway epithelial lining fluid (ELF), and alveolar cells. Population pharmacokinetic modeling generated estimates of drug exposure (Cmax and AUC) from individual-level post hoc Bayesian estimates of plasma and intrapulmonary pharmacokinetics. RESULTS One-hundred fifty-seven patients (58% HIV coinfected) participated. Despite standard weight-based dosing, peak plasma concentrations of first-line drugs were below therapeutic drug-monitoring targets. Rifampicin concentrations were low in all 3 compartments. Isoniazid, pyrazinamide, and ethambutol achieved higher concentrations in ELF and alveolar cells than plasma. Isoniazid and pyrazinamide concentrations were 14.6-fold (95% CI, 11.2-18.0-fold) and 49.8-fold (95% CI, 34.2-65.3-fold) higher in ELF than plasma, respectively. Ethambutol concentrations were highest in alveolar cells (alveolar cell-plasma ratio, 15.0; 95% CI, 11.4-18.6). Plasma or intrapulmonary pharmacokinetics did not predict clinical treatment response. CONCLUSIONS We report differential drug concentrations between plasma and the lung. While plasma concentrations were below therapeutic monitoring targets, accumulation of drugs at the site of disease may explain the success of the first-line regimen. The low rifampicin concentrations observed in all compartments lend strong support for ongoing clinical trials of high-dose rifampicin regimens.
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Affiliation(s)
- Andrew D McCallum
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Henry E Pertinez
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Laura J Else
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Sujan Dilly-Penchala
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Aaron P Chirambo
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Irene Sheha
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Madalitso Chasweka
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Alex Chitani
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Rose D Malamba
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jamilah Z Meghji
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Stephen B Gordon
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Geraint R Davies
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Saye H Khoo
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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26
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He S, Leanse LG, Feng Y. Artificial intelligence and machine learning assisted drug delivery for effective treatment of infectious diseases. Adv Drug Deliv Rev 2021; 178:113922. [PMID: 34461198 DOI: 10.1016/j.addr.2021.113922] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/14/2021] [Accepted: 08/09/2021] [Indexed: 12/23/2022]
Abstract
In the era of antimicrobial resistance, the prevalence of multidrug-resistant microorganisms that resist conventional antibiotic treatment has steadily increased. Thus, it is now unquestionable that infectious diseases are significant global burdens that urgently require innovative treatment strategies. Emerging studies have demonstrated that artificial intelligence (AI) can transform drug delivery to promote effective treatment of infectious diseases. In this review, we propose to evaluate the significance, essential principles, and popular tools of AI in drug delivery for infectious disease treatment. Specifically, we will focus on the achievements and key findings of current research, as well as the applications of AI on drug delivery throughout the whole antimicrobial treatment process, with an emphasis on drug development, treatment regimen optimization, drug delivery system and administration route design, and drug delivery outcome prediction. To that end, the challenges of AI in drug delivery for infectious disease treatments and their current solutions and future perspective will be presented and discussed.
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Affiliation(s)
- Sheng He
- Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Leon G Leanse
- Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Yanfang Feng
- Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
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27
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Denti P, Wasmann RE, van Rie A, Winckler J, Bekker A, Rabie H, Hesseling AC, van der Laan LE, Gonzalez-Martinez C, Zar HJ, Davies G, Wiesner L, Svensson EM, McIlleron HM. Optimizing dosing and fixed-dose combinations of rifampicin, isoniazid, and pyrazinamide in pediatric patients with tuberculosis: a prospective population pharmacokinetic study. Clin Infect Dis 2021; 75:141-151. [PMID: 34665866 DOI: 10.1093/cid/ciab908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In 2010, the WHO revised dosing guidelines for treatment of childhood tuberculosis. Our aim was to investigate first-line antituberculosis drug exposures under these guidelines, explore dose optimization using the current dispersible fixed-dose combination (FDC) table of rifampicin/isoniazid/pyrazinamide; 75/50/150 mg , and suggest a new FDC with revised weight-bands. METHODS Children with drug-susceptible tuberculosis in Malawi and South Africa underwent pharmacokinetic sampling while receiving first-line tuberculosis drugs as single formulations according the 2010 WHO recommended doses. Nonlinear mixed-effects modelling and simulation was used to design the optimal FDC and weight-band dosing strategy for achieving the pharmacokinetic targets based on literature-derived adult AUC0-24h for rifampicin (38.7-72.9) isoniazid (11.6-26.3) and pyrazinamide (233-429 mg∙h/L). RESULTS 180 children (42% female; 13.9% HIV-infected; median [range] age 1.9 [0.22-12] years; weight 10.7 [3.20-28.8] kg) were administered 1, 2, 3, or 4 FDC tablets (rifampicin/isoniazid/pyrazinamide 75/50/150 mg) daily for 4-8, 8-12, 12-16, and 16-25 kg weight-bands, respectively. Rifampicin exposure (for weight and age) was up to 50% lower than in adults. Increasing the tablet number resulted in adequate rifampicin but relatively high isoniazid and pyrazinamide exposures. Administering 1, 2, 3, or 4 optimized FDC tablets (rifampicin/isoniazid/pyrazinamide 120/35/130 mg) to children <6, 6-13, 13-20 and 20-25 kg, and 0.5 tablet in <3-month-olds with immature metabolism, improved exposures to all three drugs. CONCLUSION Current pediatric FDC doses resulted in low rifampicin exposures. Optimal dosing of all drugs cannot be achieved with the current FDCs. We propose a new FDC formulation and revised weight-bands.
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Affiliation(s)
- Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Annelies van Rie
- Family Medicine and Population Health, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Jana Winckler
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adrie Bekker
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health and FAMily Centre for Research with Ubuntu (FAMCRU) Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Louvina E van der Laan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carmen Gonzalez-Martinez
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi/Liverpool School of Tropical Medicine
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, South Africa
| | - Gerry Davies
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.,Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Helen M McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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28
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Comparative Effectiveness of Methotrexate versus Methylprednisolone in Treatment Naïve Pulmonary Sarcoidosis Patients. Diagnostics (Basel) 2021; 11:diagnostics11081401. [PMID: 34441335 PMCID: PMC8392209 DOI: 10.3390/diagnostics11081401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022] Open
Abstract
Among those who study granulomatous diseases, sarcoidosis is of tremendous interest, not only because its cause is unknown, but also because it is still as much an enigma today as it was 150 years ago when Jonathan Hutchinson first described the cutaneous form of the disease as “livid papillary psoriasis”. This piece editorializes a comparative effectiveness study of methotrexate versus methylprednisolone in treatment naïve pulmonary sarcoidosis patients for CT-guided clinical responses and drug-related adverse events.
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29
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Cicchese JM, Sambarey A, Kirschner D, Linderman JJ, Chandrasekaran S. A multi-scale pipeline linking drug transcriptomics with pharmacokinetics predicts in vivo interactions of tuberculosis drugs. Sci Rep 2021; 11:5643. [PMID: 33707554 PMCID: PMC7971003 DOI: 10.1038/s41598-021-84827-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
Abstract
Tuberculosis (TB) is the deadliest infectious disease worldwide. The design of new treatments for TB is hindered by the large number of candidate drugs, drug combinations, dosing choices, and complex pharmaco-kinetics/dynamics (PK/PD). Here we study the interplay of these factors in designing combination therapies by linking a machine-learning model, INDIGO-MTB, which predicts in vitro drug interactions using drug transcriptomics, with a multi-scale model of drug PK/PD and pathogen-immune interactions called GranSim. We calculate an in vivo drug interaction score (iDIS) from dynamics of drug diffusion, spatial distribution, and activity within lesions against various pathogen sub-populations. The iDIS of drug regimens evaluated against non-replicating bacteria significantly correlates with efficacy metrics from clinical trials. Our approach identifies mechanisms that can amplify synergistic or mitigate antagonistic drug interactions in vivo by modulating the relative distribution of drugs. Our mechanistic framework enables efficient evaluation of in vivo drug interactions and optimization of combination therapies.
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Affiliation(s)
- Joseph M. Cicchese
- grid.214458.e0000000086837370Department of Chemical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Awanti Sambarey
- grid.214458.e0000000086837370Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Denise Kirschner
- grid.214458.e0000000086837370Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI USA
| | - Jennifer J. Linderman
- grid.214458.e0000000086837370Department of Chemical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Sriram Chandrasekaran
- grid.214458.e0000000086837370Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI USA
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30
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Srivastava S, Cirrincione KN, Deshpande D, Gumbo T. Tedizolid, Faropenem, and Moxifloxacin Combination With Potential Activity Against Nonreplicating Mycobacterium tuberculosis. Front Pharmacol 2021; 11:616294. [PMID: 33542690 PMCID: PMC7851080 DOI: 10.3389/fphar.2020.616294] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background:Mycobacteriumtuberculosis [Mtb] could be present in different metabolic population in the lung lesions, and nonreplicating persisters [NRP], associated with latent tuberculosis [TB], are the most difficult to kill. Objective: Test the combination of tedizolid, moxifloxacin, and faropenem for activity against NRP using Mtb SS18b in the hollow fiber model [HFS-TB]. Methods: Tedizolid and moxifloxacin were tested as, first, two-drug combination against log-phase growth [LPG] and, second, slowly replicating bacilli [SRB] under acidic condition and with faropenem to create a three-drug combination regimen. Finally, standard regimen [isoniazid-rifampin-pyrazinamide] was used as comparator in the HFS-TB experiment with NRP Mtb. HFS-TB units were sampled for drug-concentration measurement as well as for estimation of bacterial burden using solid agar and mycobacterial growth indicator tube [MGIT] method. Linear regression was used to calculate the kill slopes with each treatment regimen and analysis of variance (ANOVA) to compare the regimen. Results: Tedizolid at standard dose in combination with high-dose moxifloxacin killed 3.05 log10 CFU/ml LPG Mtb and 7.37 log10 CFU/ml SRB in the bactericidal and sterilizing activity HFS-TB experiments, respectively. There was no statistical difference between tedizolid-moxifloxacin-faropenem combination and the standard regimen as both killed 7.35 log10 CFU/ml NRP Mtb in 21 days. There was no emergence of resistance to any of the drugs studied in the three HFS-TB experiments. Conclusion: The experimental regimen of tedizolid, moxifloxacin, and faropenem could effectively kill NRP population of Mtb, and given the efficacy against different metabolic population of Mtb could serve as a pan-TB regimen. Clinical studies are warranted to validate the in vitro findings.
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Affiliation(s)
- Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, United States.,Department of Immunology, UT Southwestern Medical Center, Dallas, TX, United States.,Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Kayle N Cirrincione
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, United States.,Praedicare Laboratories and Quantitative Preclinical & Clinical Sciences Department Praedicare Inc., Dallas, TX, United States.,Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
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31
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Alffenaar JWC, Gumbo T, Dooley KE, Peloquin CA, Mcilleron H, Zagorski A, Cirillo DM, Heysell SK, Silva DR, Migliori GB. Integrating Pharmacokinetics and Pharmacodynamics in Operational Research to End Tuberculosis. Clin Infect Dis 2021; 70:1774-1780. [PMID: 31560376 PMCID: PMC7146003 DOI: 10.1093/cid/ciz942] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/20/2019] [Indexed: 12/11/2022] Open
Abstract
Tuberculosis (TB) elimination requires innovative approaches. The new Global Tuberculosis Network (GTN) aims to conduct research on key unmet therapeutic and diagnostic needs in the field of TB elimination using multidisciplinary, multisectorial approaches. The TB Pharmacology section within the new GTN aims to detect and study the current knowledge gaps, test potential solutions using human pharmacokinetics informed through preclinical infection systems, and return those findings to the bedside. Moreover, this approach would allow prospective identification and validation of optimal shorter therapeutic durations with new regimens. Optimized treatment using available and repurposed drugs may have an increased impact when prioritizing a person-centered approach and acknowledge the importance of age, gender, comorbidities, and both social and programmatic environments. In this viewpoint article, we present an in-depth discussion on how TB pharmacology and the related strategies will contribute to TB elimination.
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Affiliation(s)
- Jan-Willem C Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Kelly E Dooley
- Division of Clinical Pharmacology, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Helen Mcilleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andre Zagorski
- Management Sciences for Health, Arlington, Virginia, USA
| | - Daniela M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, Virginia, USA
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
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Evaluation of Ceftriaxone Plus Avibactam in an Intracellular Hollow Fiber Model of Tuberculosis: Implications for the Treatment of Disseminated and Meningeal Tuberculosis in Children. Pediatr Infect Dis J 2020; 39:1092-1100. [PMID: 32773662 PMCID: PMC7654946 DOI: 10.1097/inf.0000000000002857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ceftazidime-avibactam is an effective agent for the treatment of tuberculosis (TB) but requires frequent administration because of a short half-life. Due to a longer half-life, ceftriaxone could allow intermittent dosing. METHODS First, we identified the MIC of ceftriaxone with 15 mg/L avibactam in 30 clinical Mycobacterium tuberculosis isolates. Next, 2 ceftriaxone exposure-effect studies in the intracellular hollow fiber model of TB (HFS-TB) that mimics disseminated disease in young children, were performed. Ceftriaxone was administered once or twice daily for 28 days to explore percentage of time that the concentration persisted above MIC (%TMIC) ranging from 0 to 100%. In a third HFS-TB experiment, the "double cephalosporin" regimen of ceftazidime-ceftriaxone-avibactam was examined and analyzed using Bliss Independence. CONCLUSION The MIC99 of the clinical strains was 32 mg/L, in the presence of 15 mg/L avibactam. Ceftriaxone %TMIC <42 had no microbial effect in the HFS-TB, %TMIC >54% demonstrated a 4.1 log10 colony-forming units per milliliter M. tuberculosis kill, while %TMIC mediating Emax was 68%. The "double cephalosporin" combination was highly synergistic. Monte Carlo experiments of 10,000 subjects identified the optimal ceftriaxone dose as 100 mg/kg twice a day. CONCLUSION The combination of ceftriaxone-avibactam at 100 mg/kg could achieve Emax in >90% of children. The ceftriaxone potent activity M. tuberculosis could potentially shorten therapy in children with disseminated TB.
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Märtson AG, Burch G, Ghimire S, Alffenaar JWC, Peloquin CA. Therapeutic drug monitoring in patients with tuberculosis and concurrent medical problems. Expert Opin Drug Metab Toxicol 2020; 17:23-39. [PMID: 33040625 DOI: 10.1080/17425255.2021.1836158] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) has been recommended for treatment optimization in tuberculosis (TB) but is only is used in certain countries e.g. USA, Germany, the Netherlands, Sweden and Tanzania. Recently, new drugs have emerged and PK studies in TB are continuing, which contributes further evidence for TDM in TB. The aim of this review is to provide an update on drugs used in TB, treatment strategies for these drugs, and TDM to support broader implementation. AREAS COVERED This review describes the different drug classes used for TB, multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), along with their pharmacokinetics, dosing strategies, TDM and sampling strategies. Moreover, the review discusses TDM for patient TB and renal or liver impairment, patients co-infected with HIV or hepatitis, and special patient populations - children and pregnant women. EXPERT OPINION TB treatment has a long history of using 'one size fits all.' This has contributed to treatment failures, treatment relapses, and the selection of drug-resistant isolates. While challenging in resource-limited circumstances, TDM offers the clinician the opportunity to individualize and optimize treatment early in treatment. This approach may help to refine treatment and thereby reduce adverse effects and poor treatment outcomes. Funding, training, and randomized controlled trials are needed to advance the use of TDM for patients with TB.
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Affiliation(s)
- Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands
| | - Gena Burch
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida , Gainesville, FL, USA
| | - Samiksha Ghimire
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands.,Department of Pharmacy, Westmead Hospital , Sydney, Australia.,Sydney Pharmacy School, The University of Sydney , Sydney, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney , Sydney, Australia
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida , Gainesville, FL, USA
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Fanelli U, Pappalardo M, Chinè V, Gismondi P, Neglia C, Argentiero A, Calderaro A, Prati A, Esposito S. Role of Artificial Intelligence in Fighting Antimicrobial Resistance in Pediatrics. Antibiotics (Basel) 2020; 9:antibiotics9110767. [PMID: 33139605 PMCID: PMC7692722 DOI: 10.3390/antibiotics9110767] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/16/2022] Open
Abstract
Artificial intelligence (AI) is a field of science and engineering concerned with the computational understanding of what is commonly called intelligent behavior. AI is extremely useful in many human activities including medicine. The aim of our narrative review is to show the potential role of AI in fighting antimicrobial resistance in pediatric patients. We searched for PubMed articles published from April 2010 to April 2020 containing the keywords “artificial intelligence”, “machine learning”, “antimicrobial resistance”, “antimicrobial stewardship”, “pediatric”, and “children”, and we described the different strategies for the application of AI in these fields. Literature analysis showed that the applications of AI in health care are potentially endless, contributing to a reduction in the development time of new antimicrobial agents, greater diagnostic and therapeutic appropriateness, and, simultaneously, a reduction in costs. Most of the proposed AI solutions for medicine are not intended to replace the doctor’s opinion or expertise, but to provide a useful tool for easing their work. Considering pediatric infectious diseases, AI could play a primary role in fighting antibiotic resistance. In the pediatric field, a greater willingness to invest in this field could help antimicrobial stewardship reach levels of effectiveness that were unthinkable a few years ago.
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Affiliation(s)
- Umberto Fanelli
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
| | - Marco Pappalardo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
| | - Vincenzo Chinè
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
| | - Pierpacifico Gismondi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
| | - Cosimo Neglia
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
| | - Adriana Calderaro
- Microbiology and Virology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Andrea Prati
- Department of Engineering and Architecture, University of Parma, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (U.F.); (M.P.); (V.C.); (P.G.); (C.N.); (A.A.)
- Correspondence: ; Tel.: +39-0521-704790
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Sibandze DB, Magazi BT, Malinga LA, Maningi NE, Shey BA, Pasipanodya JG, Mbelle NN. Machine learning reveals that Mycobacterium tuberculosis genotypes and anatomic disease site impacts drug resistance and disease transmission among patients with proven extra-pulmonary tuberculosis. BMC Infect Dis 2020; 20:556. [PMID: 32736602 PMCID: PMC7393820 DOI: 10.1186/s12879-020-05256-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 07/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background There is a general dearth of information on extrapulmonary tuberculosis (EPTB). Here, we investigated Mycobacterium tuberculosis (Mtb) drug resistance and transmission patterns in EPTB patients treated in the Tshwane metropolitan area, in South Africa. Methods Consecutive Mtb culture-positive non-pulmonary samples from unique EPTB patients underwent mycobacterial genotyping and were assigned to phylogenetic lineages and transmission clusters based on spoligotypes. MTBDRplus assay was used to search mutations for isoniazid and rifampin resistance. Machine learning algorithms were used to identify clinically meaningful patterns in data. We computed odds ratio (OR), attributable risk (AR) and corresponding 95% confidence intervals (CI). Results Of the 70 isolates examined, the largest cluster comprised 25 (36%) Mtb strains that belonged to the East Asian lineage. East Asian lineage was significantly more likely to occur within chains of transmission when compared to the Euro-American and East-African Indian lineages: OR = 10.11 (95% CI: 1.56–116). Lymphadenitis, meningitis and cutaneous TB, were significantly more likely to be associated with drug resistance: OR = 12.69 (95% CI: 1.82–141.60) and AR = 0.25 (95% CI: 0.06–0.43) when compared with other EPTB sites, which suggests that poor rifampin penetration might be a contributing factor. Conclusions The majority of Mtb strains circulating in the Tshwane metropolis belongs to East Asian, Euro-American and East-African Indian lineages. Each of these are likely to be clustered, suggesting on-going EPTB transmission. Since 25% of the drug resistance was attributable to sanctuary EPTB sites notorious for poor rifampin penetration, we hypothesize that poor anti-tuberculosis drug dosing might have a role in the development of resistance.
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Affiliation(s)
- Doctor B Sibandze
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,National Tuberculosis Control Program, Ministry of Health, Manzini, Kingdom of Eswatini
| | - Beki T Magazi
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tshwane Division, National Health Laboratory Services, Pretoria, South Africa
| | - Lesibana A Malinga
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa
| | - Nontuthuko E Maningi
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa
| | - Bong-Akee Shey
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa
| | - Jotam G Pasipanodya
- Center For Infectious Diseases Research and Experimental Therapeutics, Texas Tech University Health Sciences Center, 5920 Forest Park Road, Dallas, TX, 75235, USA. .,Praedicare Laboratories, 14830 Venture Drive, Dallas, TX, 75234, USA.
| | - Nontombi N Mbelle
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tshwane Division, National Health Laboratory Services, Pretoria, South Africa
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Cicchese JM, Dartois V, Kirschner DE, Linderman JJ. Both Pharmacokinetic Variability and Granuloma Heterogeneity Impact the Ability of the First-Line Antibiotics to Sterilize Tuberculosis Granulomas. Front Pharmacol 2020; 11:333. [PMID: 32265707 PMCID: PMC7105635 DOI: 10.3389/fphar.2020.00333] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Tuberculosis (TB) remains as one of the world's deadliest infectious diseases despite the use of standardized antibiotic therapies. Recommended therapy for drug-susceptible TB is up to 6 months of antibiotics. Factors that contribute to lengthy regimens include antibiotic underexposure in lesions due to poor pharmacokinetics (PK) and complex granuloma compositions, but it is difficult to quantify how individual antibiotics are affected by these factors and to what extent these impact treatments. We use our next-generation multi-scale computational model to simulate granuloma formation and function together with antibiotic pharmacokinetics and pharmacodynamics, allowing us to predict conditions leading to granuloma sterilization. In this work, we focus on how PK variability, determined from human PK data, and granuloma heterogeneity each quantitatively impact granuloma sterilization. We focus on treatment with the standard regimen for TB of four first-line antibiotics: isoniazid, rifampin, ethambutol, and pyrazinamide. We find that low levels of antibiotic concentration due to naturally occurring PK variability and complex granulomas leads to longer granuloma sterilization times. Additionally, the ability of antibiotics to distribute in granulomas and kill different subpopulations of bacteria contributes to their specialization in the more efficacious combination therapy. These results can inform strategies to improve antibiotic therapy for TB.
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Affiliation(s)
- Joseph M Cicchese
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Véronique Dartois
- Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States.,Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, United States
| | - Denise E Kirschner
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Jennifer J Linderman
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States
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Affiliation(s)
- K K Chopra
- Director, New Delhi Tuberculosis Centre, New Delhi, India; Associate Executive Editor, Indian Journal of Tuberculosis, India
| | - V K Arora
- Vice Chairman (P&R), TB Association of India, India; Executive Editor, Indian Journal of Tuberculosis, India.
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Abstract
Pyrazinamide (PZA) is a cornerstone antimicrobial drug used exclusively for the treatment of tuberculosis (TB). Due to its ability to shorten drug therapy by 3 months and reduce disease relapse rates, PZA is considered an irreplaceable component of standard first-line short-course therapy for drug-susceptible TB and second-line treatment regimens for multidrug-resistant TB. Despite over 60 years of research on PZA and its crucial role in current and future TB treatment regimens, the mode of action of this unique drug remains unclear. Defining the mode of action for PZA will open new avenues for rational design of novel therapeutic approaches for the treatment of TB. In this review, we discuss the four prevailing models for PZA action, recent developments in modulation of PZA susceptibility and resistance, and outlooks for future research and drug development.
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Ordonez AA, Wang H, Magombedze G, Ruiz-Bedoya CA, Srivastava S, Chen A, Tucker EW, Urbanowski ME, Pieterse L, Fabian Cardozo E, Lodge MA, Shah MR, Holt DP, Mathews WB, Dannals RF, Gobburu JVS, Peloquin CA, Rowe SP, Gumbo T, Ivaturi VD, Jain SK. Dynamic imaging in patients with tuberculosis reveals heterogeneous drug exposures in pulmonary lesions. Nat Med 2020; 26:529-534. [PMID: 32066976 DOI: 10.1038/s41591-020-0770-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/15/2020] [Indexed: 11/09/2022]
Abstract
Tuberculosis (TB) is the leading cause of death from a single infectious agent, requiring at least 6 months of multidrug treatment to achieve cure1. However, the lack of reliable data on antimicrobial pharmacokinetics (PK) at infection sites hinders efforts to optimize antimicrobial dosing and shorten TB treatments2. In this study, we applied a new tool to perform unbiased, noninvasive and multicompartment measurements of antimicrobial concentration-time profiles in humans3. Newly identified patients with rifampin-susceptible pulmonary TB were enrolled in a first-in-human study4 using dynamic [11C]rifampin (administered as a microdose) positron emission tomography (PET) and computed tomography (CT). [11C]rifampin PET-CT was safe and demonstrated spatially compartmentalized rifampin exposures in pathologically distinct TB lesions within the same patients, with low cavity wall rifampin exposures. Repeat PET-CT measurements demonstrated independent temporal evolution of rifampin exposure trajectories in different lesions within the same patients. Similar findings were recapitulated by PET-CT in experimentally infected rabbits with cavitary TB and confirmed using postmortem mass spectrometry. Integrated modeling of the PET-captured concentration-time profiles in hollow-fiber bacterial kill curve experiments provided estimates on the rifampin dosing required to achieve cure in 4 months. These data, capturing the spatial and temporal heterogeneity of intralesional drug PK, have major implications for antimicrobial drug development.
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Affiliation(s)
- Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hechuan Wang
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center and Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Camilo A Ruiz-Bedoya
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center and Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Allen Chen
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael E Urbanowski
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa Pieterse
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Fabian Cardozo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Martin A Lodge
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maunank R Shah
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel P Holt
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William B Mathews
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert F Dannals
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Steven P Rowe
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center and Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Vijay D Ivaturi
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Pasipanodya JG, Smythe W, Merle CS, Olliaro PL, Deshpande D, Magombedze G, McIlleron H, Gumbo T. Artificial intelligence-derived 3-Way Concentration-dependent Antagonism of Gatifloxacin, Pyrazinamide, and Rifampicin During Treatment of Pulmonary Tuberculosis. Clin Infect Dis 2019; 67:S284-S292. [PMID: 30496458 DOI: 10.1093/cid/ciy610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background In the experimental arm of the OFLOTUB trial, gatifloxacin replaced ethambutol in the standard 4-month regimen for drug-susceptible pulmonary tuberculosis. The study included a nested pharmacokinetic (PK) study. We sought to determine if PK variability played a role in patient outcomes. Methods Patients recruited in the trial were followed for 24 months, and relapse ascertained using spoligotyping. Blood was drawn for drug concentrations on 2 separate days during the first 2 months of therapy, and compartmental PK analyses was performed. Failure to attain sustained sputum culture conversion at the end of treatment, relapse, or death during follow-up defined therapy failure. In addition to standard statistical analyses, we utilized an ensemble of machine-learning methods to identify patterns and predictors of therapy failure from among 27 clinical and laboratory features. Results Of 126 patients, 95 (75%) had favorable outcomes and 19 (15%) failed therapy, relapsed, or died. Pyrazinamide and rifampicin peak concentrations and area under the concentration-time curves (AUCs) were ranked higher (more important) than gatifloxacin AUCs. The distribution of individual drug concentrations and their ranking varied significantly between South African and West African trial sites; however, drug concentrations still accounted for 31% and 75% of variance of outcomes, respectively. We identified a 3-way antagonistic interaction of pyrazinamide, gatifloxacin, and rifampicin concentrations. These negative interactions disappeared if rifampicin peak concentration was above 7 mg/L. Conclusions Concentration-dependent antagonism contributed to death, relapse, and therapy failure but was abrogated by high rifampicin concentrations. Therefore, increasing both rifampin and gatifloxacin doses could improve outcomes. Clinical Trials Registration NCT00216385.
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Affiliation(s)
- Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Wynand Smythe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Corinne S Merle
- Faculty of Epidemiology and Population Health, Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, United Kingdom.,Special Programme on Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Piero L Olliaro
- Special Programme on Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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Deshpande D, Pasipanodya JG, Srivastava S, Bendet P, Koeuth T, Bhavnani SM, Ambrose PG, Smythe W, McIlleron H, Thwaites G, Gumusboga M, Van Deun A, Gumbo T. Gatifloxacin Pharmacokinetics/Pharmacodynamics-based Optimal Dosing for Pulmonary and Meningeal Multidrug-resistant Tuberculosis. Clin Infect Dis 2019; 67:S274-S283. [PMID: 30496459 DOI: 10.1093/cid/ciy618] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Gatifloxacin is used for the treatment of multidrug-resistant tuberculosis (MDR-TB). The optimal dose is unknown. Methods We performed a 28-day gatifloxacin hollow-fiber system model of tuberculosis (HFS-TB) study in order to identify the target exposures associated with optimal kill rates and resistance suppression. Monte Carlo experiments (MCE) were used to identify the dose that would achieve the target exposure in 10000 adult patients with meningeal or pulmonary MDR-TB. The optimal doses identified were validated using probit analyses of clinical data from 2 prospective clinical trials of patients with pulmonary and meningeal tuberculosis. Classification and regression-tree (CART) analyses were used to identify the gatifloxacin minimum inhibitory concentration (MIC) below which patients failed or relapsed on combination therapy. Results The target exposure associated with optimal microbial kill rates and resistance suppression in the HFS-TB was a 0-24 hour area under the concentration-time curve-to-MIC of 184. MCE identified an optimal gatifloxacin dose of 800 mg/day for pulmonary and 1200 mg/day for meningeal MDR-TB, and a clinical susceptibility breakpoint of MIC ≤ 0.5 mg/L. In clinical trials, CART identified that 79% patients failed therapy if MIC was >2 mg/L, but 98% were cured if MIC was ≤0.5 mg/L. Probit analysis of clinical data demonstrated a >90% probability of a cure in patients if treated with 800 mg/day for pulmonary tuberculosis and 1200 mg/day for meningeal tuberculosis. Doses ≤400 mg/day were suboptimal. Conclusions Gatifloxacin doses of 800 mg/day and 1200 mg/day are recommended for pulmonary and meningeal MDR-TB treatment, respectively. Gatifloxacin has a susceptible dose-dependent zone at MICs 0.5-2 mg/L.
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Affiliation(s)
- Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Paula Bendet
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Thearith Koeuth
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | | | - Paul G Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York
| | - Wynand Smythe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Guy Thwaites
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Churchill Hospital, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Armand Van Deun
- Institute of Tropical Medicine, Antwerp, Belgium.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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Bolhuis MS, Akkerman OW, Sturkenboom MGG, Ghimire S, Srivastava S, Gumbo T, Alffenaar JWC. Linezolid-based Regimens for Multidrug-resistant Tuberculosis (TB): A Systematic Review to Establish or Revise the Current Recommended Dose for TB Treatment. Clin Infect Dis 2019; 67:S327-S335. [PMID: 30496467 DOI: 10.1093/cid/ciy625] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Linezolid has been successfully used for treatment of multidrug-resistant tuberculosis (MDR-TB). However, dose- and duration-related toxicity limit its use. Here, our aim was to search relevant pharmacokinetics (PK)/pharmacodynamics (PD) literature to identify the effective PK/PD index and to define the optimal daily dose and dosing frequency of linezolid in MDR-TB regimens. The systematic search resulted in 8 studies that met inclusion criteria. A significant PK variability was observed. Efficacy of linezolid seems to be driven by area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC). Literature is inconclusive about the preferred administration of a daily dose of 600 mg. To prevent development of drug resistance, an AUC/MIC ratio of 100 in the presence of a companion drug at relevant exposure is required. A daily dose of 600 mg seems appropriate to balance between efficacy and toxicity. Being a drug with a very narrow therapeutic window, linezolid treatment may benefit from a more personalized approach, that is, measuring actual MIC values and therapeutic drug monitoring.
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Affiliation(s)
- Mathieu S Bolhuis
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen
| | - Onno W Akkerman
- Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen.,Tuberculosis Center Beatrixoord, University Medical Center Groningen, University of Groningen, Haren, The Netherlands
| | - Marieke G G Sturkenboom
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen
| | - Samiksha Ghimire
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jan-Willem C Alffenaar
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen
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43
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Zuur MA, Pasipanodya JG, van Soolingen D, van der Werf TS, Gumbo T, Alffenaar JWC. Intermediate Susceptibility Dose-Dependent Breakpoints For High-Dose Rifampin, Isoniazid, and Pyrazinamide Treatment in Multidrug-Resistant Tuberculosis Programs. Clin Infect Dis 2019; 67:1743-1749. [PMID: 29697766 DOI: 10.1093/cid/ciy346] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background Bacterial susceptibility is categorized as susceptible, intermediate-susceptible dose-dependent (ISDD), and resistant. The strategy is to use higher doses of first-line agents in the ISDD category, thereby preserving the use of these drugs. This system has not been applied to antituberculosis drugs. Pharmacokinetic/pharmacodynamic (PK/PD) target exposures, in tandem with Monte Carlo experiments, recently identified susceptibility breakpoints of 0.0312 mg/L for isoniazid, 0.0625 mg/L for rifampin, and 50 mg/L for pyrazinamide. These have been confirmed in clinical studies. Methods Target attainment studies were carried out using Monte Carlo experiments to investigate whether rifampin, isoniazid, and pyrazinamide dose increases would achieve the PK/PD target in >90% of 10000 patients with tuberculosis caused by bacteria, revealing minimum inhibitory concentrations (MICs) between the proposed and the traditional breakpoints. Results We found that an isoniazid dose of 900 mg/day identified a new ISDD MIC range of 0.0312-0.25 mg/L and resistance at MIC ≥0.5 mg/L. Rifampin 1800 mg/day would result in an ISDD of 0.0625-0.25 mg/L and resistance at MIC ≥0.5 mg/L. At a dose of pyrazinamide 4 g/day, the ISDD MIC range was 37.5-50 mg/L and resistance at MIC ≥100 mg/L. Based on MIC distributions, 93% (isoniazid), 78% (rifampin), and 27% (pyrazinamide) of isolates would be within the ISDD range. Conclusions Drug susceptibility testing at 2 concentrations delineating the ISDD range, and subsequently using higher doses, could prevent switching to a more toxic second-line treatment. Confirmatory clinical studies would provide evidence to change treatment guidelines.
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Affiliation(s)
- Marlanka A Zuur
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Dick van Soolingen
- National Institute for Public Health and the Environment, Bilthoven.,Department of Medical Microbiology, Radboud University Nijmegen Medical Centre
| | - Tjip S van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
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44
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Tucker EW, Guglieri-Lopez B, Ordonez AA, Ritchie B, Klunk MH, Sharma R, Chang YS, Sanchez-Bautista J, Frey S, Lodge MA, Rowe SP, Holt DP, Gobburu JVS, Peloquin CA, Mathews WB, Dannals RF, Pardo CA, Kannan S, Ivaturi VD, Jain SK. Noninvasive 11C-rifampin positron emission tomography reveals drug biodistribution in tuberculous meningitis. Sci Transl Med 2019; 10:10/470/eaau0965. [PMID: 30518610 DOI: 10.1126/scitranslmed.aau0965] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/01/2018] [Accepted: 11/02/2018] [Indexed: 12/14/2022]
Abstract
Tuberculous meningitis (TBM) is a devastating form of tuberculosis (TB), and key TB antimicrobials, including rifampin, have restricted brain penetration. A lack of reliable data on intralesional drug biodistribution in infected tissues has limited pharmacokinetic (PK) modeling efforts to optimize TBM treatments. Current methods to measure intralesional drug distribution rely on tissue resection, which is difficult in humans and generally limited to a single time point even in animals. In this study, we developed a multidrug treatment model in rabbits with experimentally induced TBM and performed serial noninvasive dynamic 11C-rifampin positron emission tomography (PET) over 6 weeks. Area under the curve brain/plasma ratios were calculated using PET and correlated with postmortem mass spectrometry. We demonstrate that rifampin penetration into infected brain lesions is limited, spatially heterogeneous, and decreases rapidly as early as 2 weeks into treatment. Moreover, rifampin concentrations in the cerebrospinal fluid did not correlate well with those in the brain lesions. First-in-human 11C-rifampin PET performed in a patient with TBM confirmed these findings. PK modeling predicted that rifampin doses (≥30 mg/kg) were required to achieve adequate intralesional concentrations in young children with TBM. These data demonstrate the proof of concept of PET as a clinically translatable tool to noninvasively measure intralesional antimicrobial distribution in infected tissues.
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Affiliation(s)
- Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, USA
| | - Beatriz Guglieri-Lopez
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Brittaney Ritchie
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mariah H Klunk
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Richa Sharma
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Yong S Chang
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Julian Sanchez-Bautista
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sarah Frey
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martin A Lodge
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Steven P Rowe
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel P Holt
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
| | - William B Mathews
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert F Dannals
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Vijay D Ivaturi
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA.
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. .,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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45
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Court R, Chirehwa MT, Wiesner L, de Vries N, Harding J, Gumbo T, Maartens G, McIlleron H. Effect of tablet crushing on drug exposure in the treatment of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2019; 23:1068-1074. [PMID: 31627771 PMCID: PMC7402384 DOI: 10.5588/ijtld.18.0775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Treatment outcomes in multidrug-resistant tuberculosis (MDR-TB) are poor. Due to drug toxicity and a long treatment duration, approximately half of patients are treated successfully. Medication is often crushed for patients who have difficulty swallowing whole tablets. Whether crushing tablets affects drug exposure in MDR-TB treatment is not known.OBJECTIVE AND DESIGN: We performed a sequential pharmacokinetic study in patients aged >18 years on MDR-TB treatment at two hospitals in Cape Town, South Africa. We compared the bioavailability of pyrazinamide, moxifloxacin, isoniazid (INH), ethambutol and terizidone when the tablets were crushed and mixed with water before administration vs. swallowed whole. We sampled blood at six time points over 10 h under each condition separated by 2 weeks. Non-compartmental analysis was used to derive the key pharmacokinetic measurements.RESULTS: Twenty participants completed the study: 15 were men, and the median age was 31.5 years. There was a 42% reduction in the area under the curve AUC0-10 of INH when the tablets were crushed compared with whole tablets (geometric mean ratio 58%; 90%CI 47-73). Crushing tablets of pyrazinamide, moxifloxacin, ethambutol and terizidone did not affect the bioavailability significantly.CONCLUSION: We recommend that crushing of INH tablets in the MDR-TB treatment regimen be avoided. Paediatric INH formulations may be a viable alternative if the crushing of INH tablets is indicated.
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Affiliation(s)
- R Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - M T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | | | - J Harding
- DP Marais Hospital, Cape Town, South Africa
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
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46
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Pasipanodya JG, Gumbo T. Individualizing Tuberculosis (TB) Treatment: Are TB Programs in High Burden Settings Ready for Prime Time Therapeutic Drug Monitoring? Clin Infect Dis 2019. [PMID: 29514180 DOI: 10.1093/cid/ciy184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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47
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Mass spectrometry for therapeutic drug monitoring of anti-tuberculosis drugs. CLINICAL MASS SPECTROMETRY 2019; 14 Pt A:34-45. [DOI: 10.1016/j.clinms.2018.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 11/18/2022]
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48
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Dosing tuberculosis drugs in young children: the road ahead. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:590-592. [PMID: 31324599 DOI: 10.1016/s2352-4642(19)30180-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022]
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49
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Radtke KK, Dooley KE, Dodd PJ, Garcia-Prats AJ, McKenna L, Hesseling AC, Savic RM. Alternative dosing guidelines to improve outcomes in childhood tuberculosis: a mathematical modelling study. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:636-645. [PMID: 31324596 DOI: 10.1016/s2352-4642(19)30196-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/02/2019] [Accepted: 04/25/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Malnourished and young children are particularly susceptible to severe forms of tuberculosis and poor treatment response. WHO dosing guidelines for drugs for tuberculosis treatment are based only on weight, which might lead to systematic underdosing and poor outcomes in these children. We aimed to assess and quantify the population effect of WHO guidelines for drug-susceptible tuberculosis in children in the 20 countries with the highest disease burden. METHODS We used an integrated model that linked country-specific demographic data at the individual level from the 20 countries with the highest disease burden to pharmacokinetic, outcome, and epidemiological models. We estimated tuberculosis treatment outcomes in children younger than 5 years following WHO guidelines (children are dosed by weight bands corresponding to the number of fixed-dose combination tablets [75 mg rifampicin, 50 mg isoniazid, 150 mg pyrazinamide]) and two alternative dosing strategies: one based on a proposed algorithm that uses age, weight, and available formulations, in which underweight children would receive the same drug doses as would normal weight children of the same age; and another based on an individualised algorithm without dose limitations, in which derived doses results in target exposure attainment for the typical child. FINDINGS We estimated that 57 234 (43%) of 133 302 children younger than 5 years who were treated for tuberculosis in 2017 were underdosed with WHO dosing and only 47% of children would reach the rifampicin exposure target. Underdosing and subtherapeutic exposures were more common among malnourished children than among age-matched healthy children. The proposed dosing approach improved estimated rifampicin target exposure attainment to 62% and equalised outcomes by nutritional status. An estimated third of unfavourable treatment outcomes might be resolved with this dosing strategy, saving the lives of a minimum of 2423 children in these countries annually. With individualised dosing approaches, almost all children could achieve adequate exposure for cure. INTERPRETATION This work shows that a simple change in dosing procedure to include age and nutritional status, requiring no additional measurements or new drug formulations, is one approach to improve tuberculosis treatment outcomes in children, especially malnourished children who are at high risk of mortality. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development and UK Medical Research Council.
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Affiliation(s)
- Kendra K Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Kelly E Dooley
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA.
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50
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Court R, Chirehwa MT, Wiesner L, Wright B, Smythe W, Kramer N, McIlleron H. Quality assurance of rifampicin-containing fixed-drug combinations in South Africa: dosing implications. Int J Tuberc Lung Dis 2019; 22:537-543. [PMID: 29663959 PMCID: PMC5905389 DOI: 10.5588/ijtld.17.0697] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Rifampicin (RMP) drives treatment response in drug-susceptible tuberculosis. Low RMP concentrations increase the risk of poor outcomes, and drug quality needs to be excluded as a contributor to low RMP exposure. OBJECTIVES AND DESIGN: We performed an open-label, three-way cross-over study of three licensed RMP-containing formulations widely used in South Africa to evaluate the bioavailability of RMP in a two-drug fixed-dose combination tablet (2FDC) and a four-drug FDC (4FDC) against a single-drug reference. RMP dosed at 600 mg was administered 2 weeks apart in random sequence. Plasma RMP concentrations were measured pre-dose and 1, 2, 3, 4, 6, 8 and 12 h post-dose. The area under the concentration-time curve (AUC0–12) of the FDCs was compared to the single drug reference. Simulations were used to predict the impact of our findings. RESULTS: Twenty healthy volunteers (median age 22.8 years, body mass index 24.2 kg/m2) completed the study. The AUC0–12 of the 4FDC/reference (geometric mean ratio [GMR] 78%, 90%CI 69–89) indicated an average 20% reduction in RMP bioavailability in the 4FDC. The 2FDC/reference (GMR 104%, 90%CI 97–111) was bioequivalent. Simulations suggested dose adjustments to compensate for the poor bioavailability of RMP with the 4FDC, and revised weight-band doses to prevent systematic underdosing of low-weight patients. CONCLUSION: Post-marketing surveillance of in vivo bioavailability of RMP and improved weight band-based dosing are recommended.
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Affiliation(s)
- R Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - M T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - B Wright
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, South Africa
| | - W Smythe
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, South Africa
| | - N Kramer
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, South Africa
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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