Abstract
BackgroundIncreasing incidence of multidrug-resistant Mycobacterium tuberculosis infections is hampering global tuberculosis control efforts. Kuwait is a low-tuberculosis-incidence country, and ~ 1% of M. tuberculosis strains are resistant to rifampicin and isoniazid (MDR-TB). This study detected mutations in seven genes predicting resistance to rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin in MDR-TB strains. Sequence data were combined with spoligotypes for detecting local transmission of MDR-TB in Kuwait.MethodsNinety-three MDR-TB strains isolated from 12 Kuwaiti and 81 expatriate patients and 50 pansusceptible strains were used. Phenotypic drug susceptibility was determined by MGIT 460 TB/960 system. Mutations conferring resistance to rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin were detected by genotype MTBDRplus assay and/or PCR sequencing of three rpoB regions, katG codon 315 (katG315) + inhA regulatory region, pncA, three embB regions and rpsL + rrs-500–900 regions. Spoligotyping kit was used, spoligotypes were identified by SITVIT2, and phylogenetic tree was constructed by using MIRU-VNTRplus software. Phylogenetic tree was also constructed from concatenated sequences by MEGA7 software. Additional PCR sequencing of gidB and rpsA was performed for cluster isolates.ResultsPansusceptible isolates contained wild-type sequences. Mutations in rpoB and katG and/or inhA were detected in 93/93 and 92/93 MDR-TB strains, respectively. Mutations were also detected for pyrazinamide resistance, ethambutol resistance and streptomycin resistance in MDR-TB isolates in pncA, embB and rpsL + rrs, respectively. Spoligotyping identified 35 patterns with 18 isolates exhibiting unique patterns while 75 isolates grouped in 17 patterns. Beijing genotype was most common (32/93), and 11 isolates showed nine orphan patterns. Phylogenetic analysis of concatenated sequences showed unique patterns for 51 isolates while 42 isolates grouped in 16 clusters. Interestingly, 22 isolates in eight clusters by both methods were isolated from TB patients typically within a span of 2 years. Five of eight clusters were confirmed by additional gidB and rpsA sequence data.ConclusionsOur study provides the first insight into molecular epidemiology of MDR-TB in Kuwait and identified several potential clusters of local transmission of MDR-TB involving 2–6 subjects which had escaped detection by routine surveillance studies. Prospective detection of resistance-conferring mutations can identify possible cases of local transmission of MDR-TB in low MDR-TB settings.
Highlights
Increasing incidence of multidrug-resistant Mycobacterium tuberculosis infections is hampering global tuberculosis control efforts
The multidrug-resistant tuberculosis (MDR-TB) strains were cultured from 74 pulmonary and 19 extra-pulmonary specimens at Kuwait National TB Control Laboratory (KNTCL)
Characteristics of M. tuberculosis isolates A total of 93 MDR-TB strains obtained from 93 TB patients during 2006 to 2017 and 50 fully susceptible M. tuberculosis isolates collected from 50 TB patients were used
Summary
Increasing incidence of multidrug-resistant Mycobacterium tuberculosis infections is hampering global tuberculosis control efforts. Kuwait is a low-tuberculosis-incidence country, and ~ 1% of M. tuberculosis strains are resistant to rifampicin and isoniazid (MDR-TB). In high-TB-burden countries, active TB disease cases usually occur as a result of recent infection or reinfection while in low-TB-incidence countries, most active disease cases occur as a result of reactivation of latent infection acquired few to several years earlier [2,3,4]. 558,000 people developed TB in 2017 that was resistant to rifampicin, and of these, nearly 457,000 (82%) were inflicted with Mycobacterium tuberculosis strains resistant at least to rifampicin and isoniazid, the two most effective first-line drugs (MDR-TB) [1]. The MDR-TB in resource-limited settings is difficult to treat due to lengthy, more expensive and more toxic treatment regimens which lead to higher rates of clinical failure and disease relapse [5, 6]. Rapid and accurate laboratory diagnosis of MDR-TB is crucial for effective treatment, which will limit further transmission of MDR-TB and evolution of XDRTB [1, 5]
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