anti-TB Drugs Research Articles

P-11 A CASE OF TUBERCULOSIS ADRENAL INSUFFICIENCY

Abstract Introduction Adrenal tuberculosis is rare form of extrapulmonary tuberculosis, and may cause to primary adrenal insufficiency. This report presents a case of middle age male diagnosed with adrenal tuberculosis. Tuberculosis is a major health concern worldwide. The extrapulmonary manifestations account for 5% to 15% of all cases, although adrenal tuberculosis is uncommon, it can lead to primary adrenal insufficiency and has diagnostic challenges due to its nonspecific presentation. Pulmonary Tuberculosis is still common in Iraq, although no case reports exit up to our knowledge of adrenal Tuberculosis. Clinical Case 40-year-old man, sanitation worker, presents with 3 months history of significant weight loss and fever with night sweating. He complains of nausea, occasional vomiting, fatigue, unintentional weight loss of approximately 12 kg, decreased appetite, abdominal pain and joint pain. He also reports skin hyperpigmentation particularly in the hand creases, mouth and mucous membranes of the lips. There are no respiratory symptoms such as shortness of breath or cough. The past medical history is unremarkable. There is positive family history of pulmonary tuberculosis (grandmother). He does not smoke or drink alcohol. Physical examination reveals ill-looking malnourished patient, with BP of 100/60 with postural hypotension, PR of 80 bpm and RR of 24/min. There is diffuse hyperpigmentation particularly noted in palmer creases and oral cavity. The other system examinations are normal. Laboratory investigations revealed mild normochromic normocytic anemia (Hb 11.4), and mild lymphocytosis, Na 126 mEq/l, k 4.1 mEq/l, FBS 87 mg/dl, high ESR, mild elevation of TSB 1.8 mg/dl normal renal function, morning cortisol of 0.75 Mcg/dl and morning ACTH of 1808 pg/ml. Imaging studies show a normal chest X-ray. Abdominal CT reveals bilateral adrenal enlargement in size with lobulated irregular contours and heterogeneous density exhibiting foci of calcification and central cystic/necrotic non-enhancing centers, with predominantly peripheral enhancement seen on the contrast scan. The mean density of the solid parts of the glands is around 30-40 HU on the native scan, the right adrenal measures 2.7x1.7x2.7 cm, the left adrenal measures 5.6x3.2x2.5 cm. IGRA test is positive. Adrenal biopsy was not performed because the presentation was highly suggestive of adrenal tuberculosis.The diagnosis was primary adrenal insufficiency due to adrenal tuberculosis Anti TB drugs were initiated on standard regimen of INH, Rifampicin, Pyrazinamide, and Ethambutol. Hydrocortisone replacement was initiated. The patient required higher dose of hydrocortisone (20 mg in the morning, 10 mg at 6 pm) which could be due to CYP 3A4 induction by rifampicin Fludrocortisone 0.1mg daily was also started. The patient’s symptoms improve dramatically after initiation of treatments, with gradual increase in body weight.Figure 1:Hyperpigmentation of the patient hands

Clinical and Mycobacterium tuberculosis strain characteristics of tuberculosis patients with diabetes mellitus in Changping District, Beijing, China

BackgroundDiabetes mellitus (DM) is a major risk factor for tuberculosis (TB), However, limited research exists on their clinical and strain characteristics. This study aims to investigate the correlation between these factors in TB-DM patients in Changping District. MethodsWhole genome sequencing (WGS) and drug susceptibility tests (DST) were performed on culture-positive strains. Spearman correlation analysis was used to examine risk factors and the correlation between lineage, cavities, and hemoptysis in the TB-DM population. The specificity, sensitivity, and confidence intervals for predicting phenotypic drug resistance based on genotypic resistance were calculated.ResultsAmong the 3924 TB patients, 292 had DM, showing a doubling in the proportion of TB patients with DM over seven years. Among the 144 etiologically positive TB-DM cases treated at the Changping Institute for Tuberculosis Prevention and Treatment, 75% (108/144) of the patients exhibited tuberculosis lesions that formed cavities and 12.5% (18/144) with hemoptysis. A statistically significant difference in cavity formation across different age groups was observed (r = -0.198, P < 0.05). Out of the 144 etiologically positive patients, WGS successfully revived 73 MTB strains, with Lineage 2 being predominant. No statistical difference was found between lineages and the presence of cavities or hemoptysis. The DST results showed the highest resistance rates to isoniazid and streptomycin, both at 8.2% (6/73), with approximately one-quarter of the strains resistant to at least one anti-TB drug, and about half (47.1%, 8/17) resistant to first-line drugs. The study demonstrated good specificity but suboptimal sensitivity in predicting phenotypic drug resistance based on genotypic resistance.ConclusionsThe rising incidence of diabetes in tuberculosis patients within Changping District has intensified the spread of TB, with these patients demonstrating severe illness and high drug resistance. This study aims to develop targeted prevention and management strategies, offering crucial guidance for treating co-infections of TB and DM and controlling disease spread.

Characterization of NAT, GST, and CYP2E1 Genetic Variation in Sub-Saharan African Populations: Implications for Treatment of Tuberculosis and Other Diseases.

Tuberculosis (TB) is a major health burden in Africa. Although TB is treatable, anti-TB drugs are associated with adverse drug reactions (ADRs), which are partly attributed to pharmacogenetic variation. The distribution of star alleles (haplotypes) influencing anti-TB drug metabolism is unknown in many African populations. This presents challenges in implementing genotype-guided therapy in Africa to decrease the occurrence of ADRs and enhance the efficacy of anti-TB drugs. In this study, we used StellarPGx to call variants and star alleles in NAT1, NAT2, GSTM1, GSTT1, GSTP1, and CYP2E1, from 1079 high-depth African whole genomes. We present the distribution of common, rare, and potential novel star alleles across various Sub-Saharan African (SSA) populations, in comparison with other global populations. NAT1*10 (53.6%), GSTT1*0 (65%), GSTM1*0 (48%), and NAT2*5 (17.5%) were among the predominant functionally relevant star alleles. Additionally, we predicted varying phenotype distributions for NAT1 and NAT2 (acetylation) and the glutathione-S-transferase (GST) enzymes (detoxification activity) between SSA and other global populations. Forty-seven potentially novel haplotypes were identified computationally across the genes. This study provides insight into the distribution of key variants and star alleles potentially relevant to anti-TB drug metabolism and other drugs prescribed across various African populations. The high number of potentially novel star alleles exemplifies the need for pharmacogenomics studies in the African context. Overall, our study provides a foundation for functional pharmacogenetic studies and potential implementation of pharmacogenetic testing in Africa to reduce the risk of ADRs related to treatment of TB and other diseases.

In silico identification of a phosphate marine steroid from Indonesian marine compounds as a potential inhibitor of phosphatidylinositol mannosyltransferase (PimA) in Mycobacterium tuberculosis.

A higher death rate is associated with multiple factors, including medication resistance and co-infection with the human immunodeficiency virus (HIV). This shows the need to obtain new and effective drug candidates in improving tuberculosis (TB) treatment. In addition, the phosphatidylinositol mannosyltransferase (PimA) enzyme starts the production of phosphatidyl-myo-inositol. PimA has been identified as a key enzyme and an important area for further research in the development of anti-TB drugs. Previous research investigated various applications including marine resources driven by a deeper understanding of the distinctive features of the ecosystem and the diverse array of organisms. Therefore, this research aims to investigate the potential of Indonesian marine compounds as inhibitors of PimA, with a focus on binding energy, interaction modes, and stability using docking and molecular dynamics (MD) investigation methodologies. The results show that a total of 84 Indonesian marine compounds are effectively docked to the PimA to obtain compounds 21, 27, and 33 for further investigation. Based on the MD analysis, compound 27 (desulfohaplosamate) is the most promising candidate among the new MTB-PimA inhibitors. Compounds bind to PimA, as shown by a strong affinity of -30.09kJ/mol, and form hydrogen bonds with the key amino acid residue Gly16. Furthermore, a stable complex is formed to easily analyze the antibacterial agents targeting MTB in the future.

Nuclear Magnetic Resonance Fingerprinting and Principal Component Analysis Strategies Lead to Anti-Tuberculosis Natural Product Discovery from Actinomycetes.

The increasing prevalence of drug-resistant tuberculosis (TB) underscores the urgent need for novel antimicrobial agents. This study integrates cultivation optimization, nuclear magnetic resonance (NMR) fingerprinting, and principal component analysis (PCA) to explore microbial secondary metabolites as potential anti-TB agents. Using the combined approach, 11 bioactive compounds were isolated and identified, all exhibiting anti-Mycobacterium bovis BCG activity. Notable findings include borrelidin, a potent threonyl-tRNA synthetase inhibitor with broad biological activities, and L-O-Lac-L-Val-D-O-Hiv-D-Val, a peptide isolated for the first time from a plant endophyte, demonstrating broad-spectrum antimicrobial activity. Additionally, elaiophylin and polycyclic tetramate macrolactams (PTMs) displayed significant bactericidal effects, with elaiophylin achieving complete BCG inhibition at 72 h and PTMs marking their first reported anti-TB activity. The study also identified bafilomycins as potent scaffolds for anti-TB drug development, showcasing rapid bactericidal activity at low MIC values. These findings emphasize the value of microbial metabolites as a reservoir of bioactive compounds and provide new avenues for developing next-generation anti-TB therapies.

Host-Directed Therapy with Inhalable Lovastatin Microspheres for Matrix Metalloproteinase Inhibition in Tuberculosis.

Tuberculosis (TB) triggers a robust immune response, which leads to significant destruction of the lung tissue at the site of infection, aiding in the transmission of Mycobacterium tuberculosis (Mtb) to the hosts. The excessive inflammatory response contributes heavily to extracellular matrix (ECM) damage, which is linked to high mortality rates among TB patients. Matrix metalloproteinases (MMPs), particularly MMP-2 and MMP-9, are pivotal in the breakdown of the ECM, worsening tissue destruction. In the context of host-directed therapy (HDT), a strategy aimed at modulating the immune response rather than directly targeting the pathogen, we evaluated the potential of lovastatin (LOV). LOV has shown promise in reducing MMP activity and inflammation, which could alleviate the immune-mediated pathology in TB. However, its clinical use has been limited due to poor solubility and biocompatibility, reducing its therapeutic efficacy. To overcome these limitations, we designed inhalable gelatin microspheres (GA-MS) loaded with LOV using the spray-drying technology. This approach improved the solubility and allowed for the controlled release of the drug. The resulting LOV-loaded gelatin microspheres (LOV/GA-MS) had an optimal particle size of 2.395 ± 0.67 μm, facilitating macrophage uptake due to their aerodynamic properties. In in vitro studies using Mtb-infected macrophages, LOV/GA-MS effectively suppressed MMP expression and reduced levels of pro-inflammatory cytokines at a concentration of 20 μg/mL, demonstrating substantial anti-inflammatory potential. Moreover, these microspheres showed a synergistic effect when combined with standard anti-TB drugs, enhancing the overall therapeutic efficacy in in vitro experiments. The findings suggest that inhalable LOV/GA-MS microspheres represent a promising adjunctive host-directed therapy for TB. By modulating the host's immune response and targeting key inflammatory mediators such as MMPs, this approach could mitigate lung tissue damage, improve clinical outcomes, and provide a more holistic treatment option for TB.

Evaluation of extracts from used Xpert MTB/RIF cartridges for detection of resistance to second-line anti-tuberculosis drugs in patients with multidrug-resistant tuberculosis in Ethiopia

BackgroundEarly and accurate diagnosis of drug resistance, including resistance to second-line anti-tuberculosis (TB) drugs, is crucial for the effective control and management of pre-extensively drug-resistant TB (pre-XDR-TB) and extensively drug-resistant TB (XDR-TB). The Xpert MTB/XDR assay is the WHO recommended method for detecting resistance to isoniazid and second-line anti-TB drugs when rifampicin resistance is detected. Currently, the Xpert MTB/XDR assay is not yet implemented in Ethiopia, thus the MTBDRsl assay continues to be used. However, the MTBDRsl assay requires additional patient visits and specimen collection, which can lead to delays in diagnosis and treatment initiation.ObjectiveThis study aimed to evaluate the feasibility of using extracts from used Xpert MTB/RIF cartridges for detecting resistance to second-line anti-TB drugs by MTBDRsl assay in patients with rifampicin resistant-TB (RR-TB) in Eastern and Western Oromia, Ethiopia.MethodsA cross-sectional diagnostic evaluation study was conducted from June 2020 to May 2021 at two TB Referral Laboratories in Eastern and Western Oromia, Ethiopia. Sputum samples from RR-TB patients were split, with one aliquot being subjected for Xpert testing and the other being cultured on Lowenstein-Jensen media. DNA extracted from the used Xpert cartridges was amplified by PCR and tested by MTBDRsl assay, and the results were compared to those obtained from culture isolates. To establish the detection limits, the MTBDRsl assay was performed on cartridge extracts (CEs) from a series of dilutions of drug-susceptible and multidrug-resistant TB strains.ResultsThe MTBDRsl on CEs from dilutions at ≥ 102 CFU/mL (CT ≤ 22) accurately identified susceptibility and resistance patterns for fluoroquinolones (FQL) and second-line injectable drugs (SLIDs). The MTBDRsl on rifampicin-resistant CEs from sputum samples (n = 40) yielded 100% interpretable results for FQL and 90% (4 indeterminate) interpretable results for SLIDs. All interpretable CE results showed complete agreement with the MTBDRsl results from the culture isolates.ConclusionThis study demonstrated the feasibility of using extracts from used Xpert MTB/RIF cartridges for detecting resistance to second-line anti-TB drugs using the MTBDRsl assay. This approach could mitigate the need for additional specimen collection and allow for earlier treatment initiation, potentially improving patient outcomes and reducing the transmission of drug-resistant TB strains.

Enhancing tuberculosis case notifications through mapping sales of medicine in the private sector: a quasi-experimental study in Punjab province, Pakistan

IntroductionIn Pakistan, almost one-third of people who develop tuberculosis (TB) are missed by the National TB Program (NTP). A considerable number of people with TB receive treatment in the private sector but remain unnotified. This study documents the outcomes of an intervention to identify people with TB through private pharmacy engagement, building on mapping TB medicine sales in Punjab Province.MethodsA comprehensive intervention was carried out in four districts of Punjab with high anti-TB drug sales, comprising a policy change requiring mandatory notification of TB medication sales, mapping and engaging pharmacies selling anti-TB drugs, reporting through a novel ‘eTB’ mobile application and providing support via a call center. We collected both historical and prospective TB notification data from the intervention and control districts. The primary outcome was the change in TB notifications during the intervention period compared with historical and control notifications.ResultsOver the 12-month intervention period, 15,669 people with TB were reported from 2,943 pharmacies in four districts. Among the people identified, 88% were male (n = 13,673), 95% had pulmonary disease (n = 14,969), and 4,256 (27%) were bacteriologically confirmed. Chain pharmacies (n = 14) contributed to 39% of the yield. TB notifications increased by 17,462 (+ 34%) over the baseline period compared with an 8% increase in the control districts. The number of bacteriologically confirmed notifications increased by 32% compared with 16% in the control districts. The proportion of bacteriological confirmation was similar before and during the intervention.ConclusionThe results of the largest TB intervention with pharmacies globally showed incredible potential to link people with TB who are receiving care in the private sector. Mapping TB medicine sales in the private sector with tailored interventions can contribute to closing the gap in notifications where anti-TB drug sales in the private sector are prevalent.

Thiazole - A promising scaffold for antituberculosis agents and structure-activity relationships studies.

Research on thiazole derivatives has been a popular topic in medicine and one of the most active fields in heterocyclic chemistry. Pharmacological and industrial researchers have been studying thiazole-containing derivatives in great detail because they have a lot of biological uses. These compounds are one of the best examples of a five-membered heterocyclic compound that has a lot of potential and has had a lot of success in recent decades. Investigating viable hybrid designs utilizing thiazole is critical for the development of new anti-tuberculosis medications. This article offers a thorough overview of the latest advancements in thiazole-containing hybrids, offering potential therapeutic applications as anti-TB drugs. We also discussed the structure-activity correlations (SAR) of the powerful thiazole moiety and its several functional groups, along with a few potential molecular targets.

Identification of BMVC-8C3O as a novel Pks13 inhibitor with anti-tuberculosis activity.

Given the increasing prevalence of drug-resistant tuberculosis (TB), there is an urgent demand in developing novel anti-TB medications with highly effective, safe, and utilize innovative mechanisms of action. Blocking the mycolic acid synthesis pathway is well-established to be a significant strategy in developing anti-TB drugs, and Pks13 was identified as a crucial enzyme in this process. Importantly, the modes of action of recognized Pks13 inhibitors differ from traditional anti-TB medications, highlighting Pks13 as a potential and promising target in drug development within TB treatment. In this study, we discovered a compound named BMVC-8C3O that effectively inhibited the activity of Pks13 with a 6.94μM IC50 value. The binding between BMVC-8C3O and Pks13 was validated through surface plasmon resonance (SPR) assay as well as molecular docking analysis. Moreover, the SPR assay showed that the mutation of Asn1640 and Ser1533 resulted in decreased affinity of BMVC-8C3O to Pks13. Additionally, BMVC-8C3O not only exhibited activity against Mycobacterium tuberculosis (MTB), but also displayed potential intracellular anti-TB activity in macrophages. In summary, our findings indicate that BMVC-8C3O holds great potential as a lead compound against TB.

Retrospective study of side effects of anti-tuberculosis medications and modeling of the cumulative effect of risk factors

Background and objectives. Tuberculosis (TB) remains a significant global public health challenge. Treatment for TB typically involves a multi-drug regimen. While first-line anti-TB medications are generally effective, their associated side effects (SE) can lead to considerable morbidity and hinder treatment adherence. This study aimed to evaluate the side effects of first-line anti-TB drugs in individuals aged 18 to 55 years attending the pneumo-phthisiology department in the Gharb Region of Morocco. Materials and methods. This retrospective study was conducted in Kenitra Province, Morocco. Data were collected from 189 participants using a simple random sampling method. Two binary logistic regression models were developed: the first examined the effect of sociodemographic factors on the occurrence of side effects, and the second investigated their effect on treatment discontinuation or modification. Results. Among the patients, 37% experienced side effects, primarily cutaneous (39%), gastrointestinal (23%), and neurological (10%). Treatment discontinuation or modification occurred in 21.7% of cases. Logistic regression analysis revealed that university education and specific age groups (26–36, 37–55) were protective against treatment discontinuation (aOR = 0.084, 0.23, 0.14, respectively). Conversely, low socioeconomic status and female gender were associated with increased risk (aOR = 3.74, 6.11, respectively). Conclusions. This study underscores the importance of managing side effects of anti-TB medications by identifying key risk factors. Implementing targeted strategies can improve treatment adherence and reduce TB-related morbidity.

Design, Synthesis and Biological Evaluation of Ethyl 5-(1-benzyl-1H-indol-5-yl) Isoxazole-3-Carboxylates as Antimycobacterial Agents.

The continued prevalence of drug-resistant Mycobacterium tuberculosis (Mtb) strains, particularly against first-line antitubercular (anti-TB) drugs, presents an impending public health threat that necessitates the exploration and development of New Chemical Entities (NCEs). In search of new anti-TB leads, a library of ethyl 5-(1-benzyl-1H-indol-5-yl) isoxazole-3-carboxylates were generated through a strategy of scaffold hopping from the proven isoxazole-3-carboxylate-based anti-TB pharmacophore. We evaluated their antibacterial potential against a panel of pathogenic bacteria and Mtb H37Rv strains. The majority of the compounds exhibited notable in vitro efficacy against the H37Rv strains (MIC 0.25 to 16 μg/mL) and were not cytotoxic with a Selectivity Index (SI) >10. Compound 5e (3,4-dichlorobenzyl substituent) was found to be optimally active in the lot (MIC 0.25 μg/mL) and SI >200. It also displayed equipotent activity against drug-resistant Mtb (DR-Mtb) strains. In addition, it demonstrated concentration-dependent bactericidal activity in a time-kill kinetic assay similar to first-line anti-TB drugs besides exhibiting synergistic activity with Streptomycin. Moreover, it complies with the drug-likeness characteristic, making it a promising candidate for further exploration as a probable anti-TB lead.

Toward Mycobacterium tuberculosis Virulence Inhibition: Beyond Cell Wall.

Mycobacterium tuberculosis (Mtb) is one of the most successful bacterial pathogens in human history. Even in the antibiotic era, Mtb is widespread and causes millions of new cases of tuberculosis each year. The ability to disrupt the host's innate and adaptive immunity, as well as natural persistence, complicates disease control. Tuberculosis traditional therapy involves the long-term use of several antibiotics. Treatment failures are often associated with the development of resistance to one or more drugs. The development of medicines that act on new targets will expand treatment options for tuberculosis caused by multidrug-resistant or extensively drug-resistant Mtb. Therefore, the development of drugs that target virulence factors is an attractive strategy. Such medicines do not have a direct bacteriostatic or bactericidal effect, but can disarm the pathogen so that the host immune system becomes able to eliminate it. Although cell wall-associated targets are being actively studied for anti-TB drug development, other virulence factors important for adaptation and host interaction are also worth comprehensive analysis. In this review, specific Mtb virulence factors (such as secreted phosphatases, regulatory systems, and the ESX-1 secretion system) are identified as promising targets for novel anti-virulence drug development. Additionally, models for the search of virulence inhibitors are discussed, such as virtual screening in silico, in vitro enzyme inhibition assay, the use of recombinant Mtb strains with reporter constructs, phenotypic analysis using in vitro cell infection models and specific environments.

Biomolecular Interaction of Carnosine and Anti-TB Drug: Preparation of Functional Biopeptide-Based Nanocomposites and Characterization through In Vitro and In Silico Investigations.

Host-directed therapies (HDTs) resolve excessive inflammation during tuberculosis (TB) disease, which leads to irreversible lung tissue damage. The peptide-based nanostructures possess intrinsic anti-inflammatory and antioxidant properties among HDTs. Native carnosine, a natural dipeptide with superior self-organization and functionalities, was chosen for nanoformulation. In the present work, multiscale self-assembly approaches of carnosine were developed using a solvent-mediated process (hexafluoro-2-propanol) and further linked with first-line anti-TB drugs. The organofluorine compound in a solvent is attributed to the self-assembling process with heteroatom acceptors in carnosine. In the carnosine-anti-TB drug nanocomposite, the functional moieties represent the involvement of hydrogen bonding and the electrostatic force of attraction. The minimum inhibitory concentration of carnosine-anti-TB drug composites represents an antimycobacterial effect on par with standard drugs. The silicon findings complemented the in vitro results through quantum chemical simulations, elucidating the respective binding pockets between putative Mtb drug targets and carnosine-anti-TB composites. These findings confirmed that the carnosine and anti-TB drug nanocomposites prepared through a solvent-mediated process act as a rational design for functional nanodelivery systems for sustainable TB therapeutics.

Evaluation of Body Mass Index as a Marker for Monitoring of Intensive Phase Therapy and Vitamin D Supplementation in Pulmonary TB

Background: In 2022, the success rate of tuberculosis (TB) treatment in Indonesia was 86.50%, which was below the 90.00% target. The decline in nutritional status among TB patients can result from anorexia, leading to inadequate nutrition. In TB patients, the intensive phase of treatment carries a risk of 3,021 times greater for developing malnutrition. It is associated with delayed healing, increasing the risk of death and TB recurrence. This study aimed to observe changes in body mass index (BMI) in TB patients as a marker for measuring the success of the treatment. Methods: This analytical experimental study used a one-group pre-test and post-test design, applying a purposive sampling method. The study sample included all patients diagnosed with TB who met the inclusion and exclusion criteria, with a minimum sample size of 15. Results: As many as 15 new patients were diagnosed with pulmonary TB. Height and weight measurements were taken to determine their BMI. Most respondents had a BMI below normal before therapy, with 6 people (40.00%) classified as thin. After receiving anti-TB drugs and vitamin D therapy for 2 months of intensive treatment, this number decreased to 2 people (13.30%). Results from the paired t-test showed a p-value of &lt; 0.001, indicating a statistically significant difference in nutritional status before and after two months of anti-TB drug and vitamin D therapy. Conclusion: Changes in BMI were observed in pulmonary TB patients after receiving the anti-TB drug therapy and vitamin D for two months during the intensive phase.

Safety and Effectiveness of BPaL-Based Regimens to Treat Multidrug-Resistant TB: First Experience of an Italian Tuberculosis Referral Hospital.

Background/Objectives: Tuberculosis (TB) is preventable and curable, but multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) pose significant challenges worldwide due to the limited treatment options, lengths of therapies, and high rates of treatment failure. The management of MDR-TB has been revolutionized by all oral anti-TB drug regimens that are likely to improve adherence and treatment outcomes. These regimes include bedaquiline (B), pretomanid (P), and linezolid (L) (BPaL), and moxifloxacin if resistance to fluoroquinolones is not detected (BPaLM). Based on the evidence generated by the TB-PRACTECAL and ZeNix randomized controlled trials, BPaL/BPaLM regimens are recommended over the currently recommended longer regimens in patients with MDR-TB or monoresistance to rifampin (RR). To our knowledge, no data are currently available on the implementation of BPaL/BPaLM regimens in Italy. Results: Seventeen patients completed the BPaL/BPaLM regimen, with a treatment success rate of 90% (17/19), consistent with the literature data. Eleven patients out of the nineteen retained in care (58%) complained about symptoms consistent with adverse events (AEs). No treatment interruption was necessary due to AEs. Methods: Here, we report the real-world experience of a tertiary referral hospital for TB in Italy, from 2022 to 2024, in the management, outcomes, and adverse drug reactions of a cohort of twenty-two MDR/RR patients treated with BPaL and BPaLM regimens. Conclusions: BPaL-containing regimens also serve as promising options for patients with RR/MDR-TB in terms of real-life experience, but further multicentric studies are required in Europe to confirm the efficacy of shorter regimens to eliminate MDR TB.

Prevalence of non-tuberculous mycobacteria among people with acid-fast positive presumptive tuberculosis in Mali.

Non-tuberculous mycobacteria (NTM) are environmental agents that can cause opportunistic pulmonary disease in humans and animals, often misdiagnosed as tuberculosis (TB). In this study, we describe the cases of NTM identified during the first national anti-TB drug resistance survey conducted in Mali and explore associated risk factors. Sputum was collected from people presenting for pulmonary TB diagnosis from April to December 2019, regardless of age. Microscopy-positive patients were enrolled and tested using the Xpert MTB/RIF assay. A patient who tested negative for the Mycobacterium tuberculosis complex (MTBC) was tested for the presence of mycobacteria by amplification of the IS6110 and 16SrRNA (16S) genes through double quantitative real-time PCR, followed by nested PCR and Sanger sequencing of the IS6110-negative samples for NTM species identification. 1,418 sputum smear-positive patients were enrolled, including 1,199 new cases, 211 previously treated cases, and 8 whose previous treatment history was unknown. Based on the results of Xpert MTB/RIF assay and in-house PCR methods, 1,331 (93.9%) patients were positive for MTBC, 48 (3.4%) for NTM, and no species identification was possible for 39 (2.7%). Advanced age of 65 and over with an OR 8.8 (95% CI 2.3-33.2 and p = 0.001) and previous TB treatment with an OR 3.4 (95% CI 1.2-9.6 and p = 0.016) were the risk factors statistically associated with NTM detection. M. avium complex (MAC) was the predominant NTM species, detected in 20 cases. Detection of NTM in people presumed to have TB is an ongoing challenge, confounding correct TB diagnosis. Concomitant use of microscopy and GeneXpert testing among at-risk individuals could improve patient management.

Phenotypic drug resistance and genetic mutations linked to resistance among extrapulmonary tuberculosis patients in Ethiopia: Insights from Whole Genome Sequencing.

Globally, drug-resistant tuberculosis (DR-TB) is responsible for 13% of mortality attributable to antimicrobial resistance. In Ethiopia, extrapulmonary tuberculosis (EPTB) is a significant public health challenge, and drug resistance (DR) in EPTB is often overlooked. In a cross-sectional study conducted between August 2022 and October 2023, we aimed to explore the magnitude of phenotypic drug resistance and identify genetic mutations linked to resistance using 189 Mycobacterium tuberculosis (MTB) isolates cultured from extrapulmonary clinical specimens. Additionally, we assessed the agreement of the phenotypic and whole genome sequencing (WGS) based genotypic drug resistance detection. We performed phenotypic drug sensitivity testing (pDST) using liquid culture BD BACTECTM MGITTM 960 system and WGS using Illumina NextSeq500/550. The genomic data analysis pipelines MTBSeq and TBProfiler were used to predict drug resistance-conferring mutations. The agreement between the pDST and WGS was analyzed using SPSS version 29.0 software. Our result demonstrated phenotypic resistance to at least one anti-TB drug was detected in 16.9% (32/189) of the study participants. Isoniazid-resistant rifampicin-susceptible-TB (Hr-TB) and multi-drug-resistant TB (MDR-TB) phenotypes accounted for 2.6% (5/189) and 4.2% (8/189) respectively. Prevalence of MDR-TB was 2.4% (4/170) among newly diagnosed and 21.1% (4/19) among previously treated cases. WGS identified more (14/160, 8.75%) rifampicin-resistant genotypes (RR-TB) compared to pDST (8/189, 4.2%). We have identified a putative compensatory mutation for rifampicin (rpoBSer450Leu, rpoCAsp747Ala) for the first time from an EPTB clinical specimen in Ethiopia. Overall, there was a 3.75% rifampicin mono-resistant-TB(RMR-TB) genotype, which remains undetected using the conventional pDST and represented 42.9% (6/14) of the identified RR-TB genotypes. Mutations conferring rifampicin resistance-interim (rpoB.Ser450Ala) represented the majority (83.3%) of RMR-TB. Changes in ethA genes associated with ethionamide resistance were the most common resistance (n=7, 87.5%) in MDR-TB cases. There was a strong agreement between the pDST and WGS-TB Profiler pipeline to detect RR-TB (kappa=0.8) compared to the MTBSeq pipeline (k=0.58). In conclusion, MDR-TB, Hr-TB, and interim-RMR-TB are equally important public health challenges in the realm of EPTB in Ethiopia. The role of WGS is tremendous in detecting borderline/interim RMR-TB, which will help for tailored, personalized treatment strategies.

Trans-nasal brain delivery of anti-TB drugs by methyl-β-cyclodextrin microparticles show efficient mycobacterial clearance from central nervous system.

Central nervous system tuberculosis (CNS-TB) is the most severe extra-pulmonary manifestation of tuberculosis (TB), facing significant challenges due to the limited penetration of anti-TB drugs (ATDs) across the blood-brain barrier (BBB) and their insufficient concentrations at the site of infection. This study aimed to enhance the efficacy of ATDs by encapsulating them in methyl-β-cyclodextrin (M-β-CD) microparticles (ATD-MP) using spray drying, intended for intranasal delivery to manage CNS-TB. M-β-CD microparticles loaded with isoniazid (INH) and rifampicin (RIF) exhibited spherical shapes with slightly deflated surfaces and particle sizes of 6.24 ± 0.77 μm and 5.97 ± 0.50 μm, respectively. M-β-CD improved the permeation of ATDs through RPMI-2650 cell monolayers while reducing drug cytotoxicity. Pharmacokinetic and biodistribution analysis demonstrated that intranasal administration of ATD-MP significantly enhanced the trans-nasal brain delivery of ATDs and their distribution in the brain, achieving the minimum inhibitory concentration. In a murine model of CNS-TB, intranasal insufflation of ATD-MP for four weeks led to a significant reduction (~0.78 Log10 CFU) in mycobacterial burden in the brain compared to the untreated group (~3.60 Log10 CFU). These preclinical results underscore the potential of intranasal administration of M-β-CD microparticles as an effective therapeutic strategy for combating brain inflammation in CNS-TB.

Identification of Factors Determining Patterns of Serum C-Reactive Protein Level Reduction in Response to Treatment Initiation in Patients with Drug-Susceptible Pulmonary Tuberculosis.

Background: Serum C-reactive protein (CRP) levels vary depending on radiological and bacteriological findings at the time of tuberculosis (TB) diagnosis. However, the utility of this biomarker in monitoring response to anti-TB treatment and identifying patients at risk of treatment failure is not well established. Objectives: This study evaluated the impact of patients' baseline characteristics and anti-TB drug plasma exposure on the early reduction in serum CRP levels and its relationship with treatment response. Methods: We enrolled 42 patients with drug-susceptible pulmonary TB, who received a standard six-month regimen. The plasma concentrations of four anti-TB drugs were analysed using LC-MS/MS. Clinically relevant data, including serum CRP levels before and 10-12 days after treatment initiation (CRP10-12d), were obtained from electronic medical records and patient questionnaires. Results: In 10-12 days, the median serum CRP level decreased from 21.9 to 6.4 mg/L. Lower body mass index, positive sputum-smear microscopy results, and lung cavitations at diagnosis were related to higher biomarker levels at both time points; smoking had a more pronounced effect on serum CRP10-12d levels. Variability in anti-TB drug plasma exposure did not significantly affect the reduction in serum CRP levels. The serum CRP10-12d levels, or fold change from the baseline, did not predict the time to sputum culture conversion. Conclusions: Disease severity and patient characteristics may influence the pattern of early CRP reduction, while anti-TB drug plasma exposure had no significant effect at this stage. These early changes in serum CRP levels were not a predictor of response to anti-TB therapy.