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Castañeda-Mogollón D, Toppings NB, Kamaliddin C, Lang R, Kuhn S, Pillai DR. Amplicon Deep Sequencing Reveals Multiple Genetic Events Lead to Treatment Failure with Atovaquone-Proguanil in Plasmodium falciparum. Antimicrob Agents Chemother 2023; 67:e0170922. [PMID: 37154745 PMCID: PMC10269153 DOI: 10.1128/aac.01709-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/05/2023] [Indexed: 05/10/2023] Open
Abstract
Atovaquone-proguanil (AP) is used as treatment for uncomplicated malaria, and as a chemoprophylactic agent against Plasmodium falciparum. Imported malaria remains one of the top causes of fever in Canadian returning travelers. Twelve sequential whole-blood samples before and after AP treatment failure were obtained from a patient diagnosed with P. falciparum malaria upon their return from Uganda and Sudan. Ultradeep sequencing was performed on the cytb, dhfr, and dhps markers of treatment resistance before and during the episode of recrudescence. Haplotyping profiles were generated using three different approaches: msp2-3D7 agarose and capillary electrophoresis, and cpmp using amplicon deep sequencing (ADS). A complexity of infection (COI) analysis was conducted. De novo cytb Y268C mutants strains were observed during an episode of recrudescence 17 days and 16 h after the initial malaria diagnosis and AP treatment initiation. No Y268C mutant reads were observed in any of the samples prior to the recrudescence. SNPs in the dhfr and dhps genes were observed upon initial presentation. The haplotyping profiles suggest multiple clones mutating under AP selection pressure (COI > 3). Significant differences in COI were observed by capillary electrophoresis and ADS compared to the agarose gel results. ADS using cpmp revealed the lowest haplotype variation across the longitudinal analysis. Our findings highlight the value of ultra-deep sequencing methods in the understanding of P. falciparum haplotype infection dynamics. Longitudinal samples should be analyzed in genotyping studies to increase the analytical sensitivity.
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Affiliation(s)
- Daniel Castañeda-Mogollón
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
| | - Noah B. Toppings
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
| | - Claire Kamaliddin
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
| | - Raynell Lang
- Cumming School of Medicine, Department of Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Community Health Sciences, the University of Calgary, Calgary, Alberta, Canada
| | - Susan Kuhn
- Cumming School of Medicine, Department of Pediatrics, the University of Calgary, Calgary, Alberta, Canada
| | - Dylan R. Pillai
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Diagnostic & Scientific Centre, Calgary, Alberta, Canada
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Thapar MM, Ursing J, Ashton M, Bergqvist Y, Gil JP, Björkman A. Ketoconazole increases atovaquone exposure following concomitant administration with Malarone® in healthy subjects. J Travel Med 2022; 29:6582523. [PMID: 35532299 DOI: 10.1093/jtm/taac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Mita M Thapar
- Principal PK Scientist, Quantitative Pharmacology & Pharmacometrics, Early Phase Services, ICON Clinical Research, Reading, UK
| | - Johan Ursing
- Department of Clinical Sciences, Karolinska Institute, Stockholm, Sweden
| | - Michael Ashton
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | | | - José Pedro Gil
- Division of Parasitology, Department of Microbiology Tumour and Cell Biology (MTC), Karolinska Institute, Stockholm, Sweden
| | - Anders Björkman
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institute, Stockholm, Sweden
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Lin JT, Waltmann A, Moser KA, Park Z, Na YB, Aydemir O, Brazeau NF, Gosi P, Marsh PW, Muller MS, Spring M, Sok S, Bailey JA, Saunders DL, Lon C, Wojnarski M. Selection of Cytochrome b Mutants Is Rare among Plasmodium falciparum Patients Failing Treatment with Atovaquone-Proguanil in Cambodia. Antimicrob Agents Chemother 2021; 65:e01249-20. [PMID: 33361308 DOI: 10.1128/AAC.01249-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/18/2020] [Indexed: 11/20/2022] Open
Abstract
Atovaquone-proguanil remains effective against multidrug-resistant Plasmodium falciparum in Southeast Asia, but resistance is mediated by a single point mutation in cytochrome b (cytb) that can arise during treatment. Among 14 atovaquone-proguanil treatment failures in a clinical trial in Cambodia, only one recrudescence harbored the cytb mutation Y268C. Deep sequencing did not detect the mutation at baseline or in the first 3 days of treatment, suggesting that it arose de novo Further sequencing across cytb similarly found no low-frequency cytb mutations that were up-selected from baseline to recrudescence. Copy number amplification in dihydroorotate dehydrogenase (DHODH) and cytb as markers of atovaquone tolerance was also absent. Cytb mutation played a minor role in atovaquone-proguanil treatment failures in an active comparator clinical trial.
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IV artesunate for severe malaria. Med Lett Drugs Ther 2020; 62:121-4. [PMID: 32960866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Abstract
Pregnant travelers face numerous risks, notably increased susceptibility to or severity of multiple infections, including malaria. Because pregnant women residing in areas non-endemic for malaria are unlikely to have protective immunity, travel to endemic areas poses risk of severe illness and pregnancy complications, such as low birthweight and fetal loss. If travel to malaria-endemic areas cannot be avoided, preventive measures are critical. However, malaria chemoprophylaxis in pregnancy can be challenging, since commonly used regimens have varying levels of safety data and national guidelines differ. Furthermore, although chloroquine and mefloquine have wide acceptance for use in pregnancy, regional malaria resistance and non-pregnancy contraindications limit their use. Mosquito repellents, including N,N-diethyl-m-toluamide (DEET) and permethrin treatment of clothing, are considered safe in pregnancy and important to prevent malaria as well as other arthropod-borne infections such as Zika virus infection. Pregnant travelers at risk for malaria exposure should be advised to seek medical attention immediately if any symptoms of illness, particularly fever, develop.
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Affiliation(s)
- Kimberly L. McKinney
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA
| | - Henry M. Wu
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathrine R. Tan
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Advice for travelers. Med Lett Drugs Ther 2019; 61:153-60. [PMID: 31599872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Tafenoquine (Arakoda; Krintafel) for malaria. Med Lett Drugs Ther 2019; 61:101-4. [PMID: 31381542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Expanded table: drugs for prophylaxis of malaria. Med Lett Drugs Ther 2019; 61:e104-5. [PMID: 31381543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Kamaliddin C, Joste V, Argy N, Houzé S. [Fluindione and falciparum malaria treated by atovaquone-proguanil]. Therapie 2018; 73:445-447. [PMID: 29680373 DOI: 10.1016/j.therap.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 01/19/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Claire Kamaliddin
- Centre national de référence paludisme, site Bichat, 75018 Paris, France; UMR 216 - Mère et enfant face aux infections tropicales, université Paris-Descartes, faculté de pharmacie, 75006 Paris, France; COMUE Sorbonne Paris Cité, 75013 Paris, France.
| | - Valentin Joste
- Centre national de référence paludisme, site Bichat, 75018 Paris, France; COMUE Sorbonne Paris Cité, 75013 Paris, France; Laboratoire de parasitologie-mycologie, hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Nicolas Argy
- Centre national de référence paludisme, site Bichat, 75018 Paris, France; UMR 216 - Mère et enfant face aux infections tropicales, université Paris-Descartes, faculté de pharmacie, 75006 Paris, France; COMUE Sorbonne Paris Cité, 75013 Paris, France; Laboratoire de parasitologie-mycologie, hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Sandrine Houzé
- Centre national de référence paludisme, site Bichat, 75018 Paris, France; UMR 216 - Mère et enfant face aux infections tropicales, université Paris-Descartes, faculté de pharmacie, 75006 Paris, France; COMUE Sorbonne Paris Cité, 75013 Paris, France; Laboratoire de parasitologie-mycologie, hôpital Bichat-Claude-Bernard, 75018 Paris, France
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Boggild AK, Lau R, Reynaud D, Kain KC, Gerson M. Failure of atovaquone-proguanil malaria chemoprophylaxis in a traveler to Ghana. Travel Med Infect Dis 2014; 13:89-93. [PMID: 25582377 DOI: 10.1016/j.tmaid.2014.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 12/18/2014] [Accepted: 12/23/2014] [Indexed: 11/18/2022]
Abstract
Clinical failure of Malarone™ chemoprophylaxis is extremely rare. We report a case of Plasmodium falciparum malaria in a returned traveler to Ghana who fully adhered to atovaquone-proguanil (Malarone™) chemoprophylaxis daily dosing, yet took the pills on an empty stomach. Screening of the P. falciparum isolate revealed triple codon mutation of Dhfr at positions 51, 59, and 108. Plasma drug levels of both atovaquone and proguanil revealed sub-therapeutic concentrations.
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Affiliation(s)
- Andrea K Boggild
- Tropical Disease Unit, Division of Infectious Diseases, University Health Network-Toronto General Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada.
| | - Rachel Lau
- Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada
| | - Denis Reynaud
- The Centre for the Study of Complex Childhood Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kevin C Kain
- Tropical Disease Unit, Division of Infectious Diseases, University Health Network-Toronto General Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University of Toronto, Canada
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Plucinski MM, Huber CS, Akinyi S, Dalton W, Eschete M, Grady K, Silva-Flannery L, Mathison BA, Udhayakumar V, Arguin PM, Barnwell JW. Novel Mutation in Cytochrome B of Plasmodium falciparum in One of Two Atovaquone-Proguanil Treatment Failures in Travelers Returning From Same Site in Nigeria. Open Forum Infect Dis 2014; 1:ofu059. [PMID: 25734129 PMCID: PMC4281801 DOI: 10.1093/ofid/ofu059] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 07/01/2014] [Indexed: 11/14/2022] Open
Abstract
Background Atovaquone-proguanil (AP) is the most commonly used treatment for uncomplicated Plasmodium falciparum malaria in the United States. Apparent AP treatment failures were reported 7 months apart in 2 American travelers who stayed in the same compound for foreign workers in Rivers State, Nigeria. Methods We analyzed pretreatment (day 0) and day of failure samples from both travelers for mutations in the P falciparum cytochrome B (pfcytb) and dihydrofolate reductase (pfdhfr) genes associated with resistance to atovaquone and cycloguanil, the active metabolite of proguanil, respectively. We genotyped the parasites and sequenced their mitochondrial genomes. Results On day 0, both travelers had proguanil-resistant genotypes but atovaquone-sensitive cytb sequences. Day of failure samples exhibited mutations in cytb for both travelers. One traveler had the common Y268S mutation, whereas the other traveler had a previously unreported mutation, I258M. The travelers had unrelated parasite genotypes and different mitochondrial genomes. Conclusions Despite the infections likely having been contracted in the same site, there is no evidence that the cases were related. The mutations likely arose independently during the acute infection or treatment. Our results highlight the importance of genotyping parasites and sequencing the full cytb and dhfr genes in AP failures to rule out transmission of AP-resistant strains and identify novel mechanisms of AP resistance.
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Affiliation(s)
- Mateusz M Plucinski
- Division of Parasitic Diseases and Malaria, Center for Global Health ; Epidemic Intelligence Service , Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Curtis S Huber
- Division of Parasitic Diseases and Malaria, Center for Global Health
| | - Sheila Akinyi
- Division of Parasitic Diseases and Malaria, Center for Global Health
| | | | - Mary Eschete
- Terrebonne General Medical Center, Houma, Louisiana
| | - Katharine Grady
- Division of Parasitic Diseases and Malaria, Center for Global Health
| | | | - Blaine A Mathison
- Division of Parasitic Diseases and Malaria, Center for Global Health
| | | | - Paul M Arguin
- Division of Parasitic Diseases and Malaria, Center for Global Health
| | - John W Barnwell
- Division of Parasitic Diseases and Malaria, Center for Global Health
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Amelot A, Dupouy-Camet J, Jeanmougin M. Phototoxic reaction associated with Malarone (atovaquone/proguanil) antimalarial prophylaxis. J Dermatol 2014; 41:346-8. [PMID: 24612343 DOI: 10.1111/1346-8138.12368] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/06/2013] [Indexed: 11/30/2022]
Abstract
Phototoxic reaction has not been reported previously as an adverse reaction to the combination of atovaquone and proguanil (AP) (Malarone) used for antimalarial prophylaxis and therapy. We report here a 32-year-old patient treated with AP who presented with clinical manifestations of photosensitivity. AP-induced phototoxicity in this patient was further supported by phototesting. Malarone is not known to photosensitize and render the skin more susceptible to severe sunburn-like reactions. That it may do so, as in this case, is of importance especially as this drug is used predominantly by those travelling to sunnier climes. A notification of potential phototoxic effects of AP should be published for the choice of prophylaxis made by tourists traveling in malarial areas.
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Affiliation(s)
- Aymeric Amelot
- Department of Photodermatology, St Louis Hospital, University of Paris Descartes, Paris, France
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Nicosia V, Colombo G, Consentino M, Di Matteo S, Mika F, De Sanctis S, Ratti S, Vinci M. Assessment of acceptability and ease of use of atovaquone/proguanil medication in subjects undergoing malaria prophylaxis. Ther Clin Risk Manag 2011; 4:1105-10. [PMID: 19209290 PMCID: PMC2621421 DOI: 10.2147/tcrm.s3782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: International travelers from non-endemic areas are at high risk of contracting malaria due to their lack of immunity. Prevention is therefore of outmost importance and is achieved through effective and safe chemoprophylaxis, which reduces the risk of fatal disease. Among the various antimalarial drugs available, the synergistic combination of atovaquone and proguanil (A/P) (Malarone®; Glaxo-SmithKline) has proven a valuable option in terms of effective protection against chloroquine and multi-drug resistant falciparum malaria, safety, tolerability, and ease of use, thus favoring compliance. The purpose of the present study was to assess acceptability and ease of use of A/P chemoprophylaxis in a population of employees of the oil industry bound to malarious areas. Particular attention was paid to treatment adherence. Methods: A survey was conducted on a sample of 700 employees on A/P chemoprophylaxis. Demographic data and specific information on A/P treatment were collected by means of a 16-item questionnaire administered immediately before departure. All questionnaires returned were then entered into a database and statistically analyzed. Results: Both habitual and first-time travelers showed good adherence to A/P chemoprophylactic regimen. In general, only few adverse side-effects were reported, none of which were serious. Travelers with previous experience of other antimalarials stated A/P prophylaxis had proven advantageous due to fewer adverse reactions, better condition of administration, and better sense of protection compared with other available treatments.
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Affiliation(s)
- V Nicosia
- Saipem Medical Dept. San Donato Milanese, Italy
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