Isoniazid-resistant Tuberculosis Research Articles

KatG (SER 315 THR) Gene Mutation in Isoniazid Resistant Mycobacterium Tuberculosis

BACKGROUND Isoniazid (INH) together with Rifampicin (RFP) forms the cornerstone of a short chemotherapy course for tuberculosis (TB) treatment. Mutation at codon 315 of katG gene is most prevalent in isoniazid resistant Mycobacterium tuberculosis (MTB) and is high in area with high TB incidence. Polymerase Chain Reaction Restriction Fragment Length Polymorphism (PCR-RFLP) has been found to be a reliable and effective tool for the identification of the specific gene alteration. The objective of this study was to screen Ser315Thr mutation of KatG gene of INH resistant MTB strain by PCR-RFLP technique. Altogether 37 INHr MTB isolates obtained from German Nepal Tuberculosis Project (GENETUP) Kathmandu Nepal was included in the study. Deoxyribonucleic Acid (DNA) extraction was performed according to protocol of SORPOCLEAN from the culture isolates. Amplification of the fragment with katG codon 315 was performed in a Biometra Thermocycler using primers. The amplified fragment was cleaved with MspI. The restriction fragments obtained were electrophoresed in a 2% agarose gel and were visualized using transilluminator. The katG Ser315Thr mutation was observed in 23 (62.2%) out of 37 INH resistant isolates. The drug susceptibility profile of INHr MTB isolates showed all isolates to be resistant to INH and RFP whereas 26 and 27 MTB isolates were resistant to Ethambutol (EMB) and Streptomycin (S) respectively. Seventeen (17) patients were harbouring katG gene mutated strain among Ethambutol and Streptomycin resistant cases. The study identified high prevalence of Ser315Thr mutation in katG. The isolates harbouring this mutation were also simultaneously resistant to RFP. Ser315Th could be a potential genetic marker for predicting MDR-TB.

Latent and subclinical tuberculosis in HIV infected patients: a cross-sectional study

BackgroundHIV and tuberculosis (TB) are commonly associated. Identifying latent and asymptomatic tuberculosis infection in HIV-positive patients is important in preventing death and morbidity associated with active TB.MethodsCross-sectional study of one time use of an interferon-gamma release assay (T-SPOT.TB - immunospot) to detect tuberculosis infection in patients in a UK inner city HIV clinic with a large sub-Saharan population.Results542 patient samples from 520 patients who disclosed their symptoms of TB were tested. Median follow-up was 35 months (range 27-69). More than half (55%) originated from countries with medium or high tuberculosis burden and 57% were women. Antiretroviral therapy was used by 67%; median CD4 count at test was 458 cells/μl. A negative test was found in 452 samples and an indeterminate results in 40 (7.4%) but neither were associated with a low CD4 count. A positive test was found in 10% (50/502) individuals. All patients with positive tests were referred to the TB specialist, 47 (94%) had a chest radiograph and 46 (92%) attended the TB clinic. Two had culture-positive TB and a third individual with features of active TB was treated. 40 started and 38 completed preventive treatment. One patient who completed preventive treatment with isoniazid monotherapy subsequently developed isoniazid-resistant pulmonary tuberculosis. No patient with a negative test has developed TB.ConclusionsWe found an overall prevalence of latent TB infection of 10% through screening for TB in those with HIV infection and without symptoms, and a further 1% with active disease, a yield greater than typically found in contact tracing. Acceptability of preventive treatment was high with 85% of those with latent TB infection eventually completing their TB chemotherapy regimens. IGRA-based TB screening among HIV-infected individuals was feasible in the clinical setting and assisted with appropriate management (including preventive treatment and therapy for active disease). Follow-up of TB incidence in this group is needed to assess the long-term effects of preventive treatment.

New insight into the molecular characterization of isoniazid and rifampicin resistant Mycobacterium tuberculosis strains from Saudi Arabia

Data on the genetic variation of isolates of Mycobacterium tuberculosis and spectrum of mutations determining resistance to principal anti-tuberculosis drugs isoniazid (INH) and rifampicin (RIF) have not yet been studied in Saudi Arabia. One hundred and fifty-one clinical isolates of M. tuberculosis from different regions in the country showing resistance to RIF and INH were subjected to drug susceptibility testing, characterization of mutations conferring drug resistance and genotyping. Phenotypically 17 (11.3%) isolates were resistance to RIF, 75 (49.6%) were resistant to INH and 59 (39.1%) were resistant to both RIF and INH, respectively. Sixteen (10.6%), 74 (49%) and 56 (37.1%) were determined as resistant to RIF, INH and to both by line probe assay. High frequency of rpoB 531 mutations (67.1%) in RIF resistant strains and katG 315 mutations (65.2%) in INH resistant strains were found. Mutations responsible for INH resistance, katG 315 (P value<0.001, odds ratio: 1.81, 95% CI [1.51, 2.18]) and inhA-15 (P value – 0.004, odds ratio: 1.48, 95% CI [1.22, 1.8]) were predominant among the newly diagnosed cases. Beijing strains were significantly associated with multi drug resistance and mutations in combination of rpoB531 and katG315 (P value – <0.001, odds ratio: 6.83, 95% CI [2.65, 17.58]). In addition multi drug resistance was significantly associated with treatment history (P value<0.001, odds ratio: 3.16, 95% CI [2.14, 4.67]). Furthermore, a higher rate (39.3%) of clustering among the multidrug resistant strains particularly with Beijing family (52.9%) was observed. Saudi Arabia harbors highly diverse drug resistant M. tuberculosis population with an ongoing transmission which needs to be immediately managed.

Novel mutations in katG gene of a clinical isolate of isoniazid-resistant Mycobacterium tuberculosis

Most of isoniazid-resistant Mycobacterium tuberculosis evolved due to mutation in the katG gene encoding catalase-peroxidase. A set of new mutations, namely T1310C, G1388T, G1481A, T1553C, and A1660G, which correspond to amino acid substitutions of L437P, R463L, G494D, I518T, and K554E, in the katG gene of the L10 clinical isolate M. tuberculosis was identified. The wild-type and mutant KatG proteins were expressed in Escherichia coli BL21(DE3) as a protein of 80 kDa based on sodium dodecyl sulphate-polyacrylamide gel electrophoresis analysis. The mutant KatG protein exhibited catalase and peroxidase activities of 4.6% and 24.8% toward its wild type, respectively, and retained 19.4% isoniazid oxidation activity. The structure modelling study revealed that these C-terminal mutations might have induced formation of a new turn, perturbing the active site environment and also generated new intramolecular interactions, which could be unfavourable for the enzyme activities.

Molecular Characteristics of Rifampin- and Isoniazid-Resistant Mycobacterium tuberculosis Strains Isolated in Vietnam

Molecular characterization of the drug resistance of Mycobacterium tuberculosis strains with different origins can generate information that is useful for developing molecular methods. These methods are widely applicable for rapid detection of drug resistance. A total of 166 rifampin (RIF)- and/or isoniazid (INH)-resistant strains of M. tuberculosis have been isolated from different parts of Vietnam; they were screened for mutations associated with resistance to these drugs by sequence analysis investigating genetic mutations associated with RIF and INH resistance. Seventeen different mutations were identified in 74 RIF-resistant strains, 56 of which (approximately 76%) had mutations in the so-called 81-bp "hot-spot" region of the rpoB gene. The most common point mutations were in codons 531 (37.8%), 526 (23%), and 516 (9.46%) of the rpoB gene. Mutations were not found in three strains (4.05%). In the case of INH resistance, five different mutations in the katG genes of 82 resistant strains were detected, among which the nucleotide substitution at codon 315 (76.83%) is the most common mutation. This study provided the first molecular characterization of INH and RIF resistance of M. tuberculosis strains from Vietnam, and detection of the katG and rpoB mutations of the INH and RIF-resistant strains should be useful for rapid detection of the INH- and RIF-resistant strains by molecular tests.

Molecular characterisation of isoniazid- and rifampicin-resistant Mycobacterium tuberculosis in Central Tunisia

The aim of our study was to genotypically characterise isoniazid (INH) and rifampicin (RMP) resistant Mycobacterium tuberculosis isolates in Sousse, Central Tunisia, using DNA sequencing and multispacer sequence typing (MST). The results show that 27/28 (96.4%) and 1/28 (3.6%) INH-resistant isolates yielded respectively the kat G S315T and the inh A - 15C → T mutations. Two-thirds of RMP-resistant isolates yielded the rpo B D516V mutation and one sixth yielded either H526D or S531L mutations. Genotyping analysis revealed the multiclonal spread of drug-resistant isolates in Central Tunisia. Data presented here complete the previously published map of resistant M. tuberculosis isolates and highlight their regional disparity in Tunisia.

Molecular technologies used in detecting of sensitive and isoniazid-resistant Mycobacterium tuberculosis

Two variants for the detection of single nucleotide polymorphisms in codon 315 of the katG gene of Mycobacterium tuberculosis (MTB) (mutations in this gene are associated with resistance to isoniazid, which is an antituberculosis drug of the first line) have been developed. Two sets of primers, either of which included an additional competitive blocking primer with a 3′-terminal phosphate group (in order to prevent nonspecific amplification), permitted the identification of the most frequent AGC → ACC and AGC → AGA point mutations in codon 315 of the katG gene. Conduction of PCR with a set of two primers, one of which contained five LNA monomers, permitted the detection of any of the six known mutations in codon 315 of the katG gene and, thereby, for the discrimination between isoniazid-sensitive and isoniazid-resistant MTB. The purity and structure of the 17 bp long primers containing LNA-modified nucleotides were characterized by time-of-flight MALDI mass spectrometry, and the 17 bp duplex formed by two LNA-containing complementary oligonucleotides was analyzed by thermal denaturation. The molecular genetic test systems created for differentiating between the wild-type MTB isolates and isoniazid-resistant MTB (an antituberculosis drug of the first line) can be used in clinical laboratories equipped with standard PCR devices; such systems permit the shortening of the time required for the detection of isoniazid resistance of MTB: from 1–3 months by the standard bacteriological methods to 1–3 days by PCR.

Isoniazid resistance of Mycobacterium tuberculosis isolated from human patients

Isoniazid resistant Mycobacterium tuberculosis strains are a serious threat for successful tuberculosis control programs. Therefore, present study was aimed to figure out the pattern and level of resistance of M. tuberculosis against isoniazid. A total of 172 specimens of sputum, pus and bronchial washings; 70.9% males and 29.1% females with 84.30% pulmonary and 15.69% extrapulmonary tuberculosis were collected from six different sources. The inoculums were prepared using 0.5 Mac Farland turbidity standards. Five concentrations of isoniazid were used in Lowenstein Jensen (LJ) medium that is 3, 6, 9, 12 and + 12 μg/ml for sensitivity testing. Data showed 25 (14.5%) resistant and 147 (85.5%) sensitive M. tuberculosis strains. The growth was not inhibited at first (3 μg/ml) and second (6 μg/ml) drug levels, while 36% isolates inhibited at third level (9 μg/ml), 28% at forth level (12 μg/ml) and 24% at fifth level (10 μg/ml) and 12% at higher than fifth Level (> 12 ug/ml). These incorporated drug concentrations are higher than therapeutic index and not recommended in actual clinical practice. It is thus obvious to explore some other effective chemotherapeutic agents, modify combinations or figure out more effective procedures to stop morbidity and mortality due to isoniazide resistance ofM. tuberculosis. Key words: Isoniazid, mycobacterium tuberculosis, resistance, Lowenstein Jensen medium.

Isoniazid-Resistant Tuberculosis, Taiwan, 2000-2010

To the Editor: Vinnard et al. (1) reported that the risk factors associated with initial isoniazid resistance among patients with tuberculous meningitis in the United States during 1993–2005 included young age (25–34 years) and foreign birth (1). In a previous survey, conducted in Taiwan during 2000–2008, we found the rate of antituberculosis drug resistance to be lower for older patients than for younger patients (2); however, current information about the patient characteristics associated with isoniazid-resistant tuberculosis (TB) in Taiwan is lacking. Therefore, to determine the risk factors associated with initial isoniazid resistance among patients with TB in Taiwan, we conducted a retrospective study. The study was conducted at the National Taiwan University Hospital, a 2,500-bed tertiary care center in northern Taiwan. We analyzed culture-confirmed Mycobacterium tuberculosis isolates obtained from hospitalized patients during January 2000–December 2010. A nonduplicate isolate was defined as 1 isolate collected for evaluation from 1 patient who visited the hospital (as inpatient or outpatient). If multiple isolates were available from a patient, only the one first isolated was analyzed. All specimens were processed and pretreated as described elsewhere (3). Patients with multidrug-resistant TB were excluded on the basis of evidence for differences in the epidemiology of isoniazid-resistant (rifampin-susceptible) TB and multidrug-resistant TB (4). Immigrant populations in Taiwan are limited; therefore, we did not analyze the origin of the patients. After excluding patients with multidrug-resistant TB, we analyzed 4,289 nonduplicate isolates, of which 3,842 (89.6%) were susceptible to isoniazid and the other 447 (10.4%) were resistant to isoniazid. In terms of demographic associations, patients 34– 74 years of age to have an isoniazid-resistant strain (Table). In addition, patients with extrapulmonary TB were less likely than patients with pulmonary TB to be infected with isoniazid-resistant TB. We also identified 34 patients with TB meningitis. After excluding 2 patients with multidrug-resistant TB, we found that 31 patients (mean age 56.6 years) had isoniazid-susceptible TB meningitis and a 50-year-old man had meningitis caused by isoniazid-resistant TB. Table Factors associated with isoniazid resistance among Mycobacterium tuberculosis isolates, National Taiwan University Hospital, Taiwan, 2000–2010* Our results are in agreement with those reported in a previous study in the United States, which found that the rate of isoniazid resistance was lower for isolates from elderly patients (1,4). This phenomenon may be attributable to the reactivation of a dormant infection. Because isoniazid was introduced to Taiwan for the treatment of TB in 1952, elderly persons in Taiwan probably did not receive isoniazid if their TB developed when they were young. In the present study, the resistant rate was lower for M. tuberculosis strains isolated from elderly persons than from younger adults. These findings suggest that first-line anti-TB medications still have good in vitro activity against M. tuberculosis strains in elderly patients. In contrast to the study by Vinnard et al. (1), our results showed that isoniazid-resistant M. tuberculosis was significantly less likely to be isolated from nonrespiratory than from respiratory specimens. The reasons for this finding are unclear. Continuous monitoring of antimicrobial drug resistance among M. tuberculosis isolates isolated from various body sites needs to be incorporated into any TB surveillance program. Gathering data on drug resistance rates is a major aspect of the global TB control program. Clinicians must have knowledge of local epidemiology, and mycobacteriology laboratories should maintain up-to-date information on drug susceptibility test profiles of local M. tuberculosis isolates.

Treatment Outcomes of Isoniazid-Resistant Tuberculosis Patients, Western Cape Province, South Africa

We report treatment outcomes from a retrospective cohort of patients with isoniazid-monoresistant tuberculosis in rural South Africa. Sixteen percent of patients had poor outcomes, 61% of whom progressed to multidrug-resistant tuberculosis. These data reveal the need for early identification and aggressive follow-up of isoniazid monoresistance to increase treatment success.

Quantifying the Burden and Trends of Isoniazid Resistant Tuberculosis, 1994–2009

BackgroundQuantifying isoniazid resistant (INH-R) tuberculosis (TB) is important because isoniazid resistance reduces the probability of treatment success, may facilitate the spread of multidrug resistance, and may reduce the effectiveness of isoniazid preventive therapy (IPT).Methodology/Principal FindingsWe used data reported to the World Health Organization between 1994–2009 to estimate the INH-R burden among new and retreatment TB cases. We assessed geographical and temporal variation in INH-R and reported levels in high HIV prevalence countries (≥2%) to understand implications for IPT. 131 settings reported INH-R data since 1994. A single global estimate of the percentage of incident TB cases with INH-R was deemed inappropriate due to particularly high levels in the Eastern European region where 44.9% (95% CI: 34.0%, 55.8%) of incident TB cases had INH-R. In all other regions combined, 13.9% (95% CI: 12.6%, 15.2%) of incident cases had INH-R with the lowest regional levels seen in West/Central Europe and Africa. Where trend data existed, we found examples of rising and falling burdens of INH-R. 40% of high HIV prevalence countries reported national data on INH-R and 7.3% (95% CI: 5.5%, 9.1%) of cases in these settings had INH-R.Conclusions/SignificanceOutside the Eastern European region, one in seven incident TB cases has INH-R, while this rises to nearly half within Eastern Europe. Many countries cannot assess trends in INH-R and the scarcity of data from high HIV prevalence areas limits insight into the implications for IPT. Further research is required to understand reasons for the observed time trends and to determine the effects of INH-R for control of TB.

Genotypic and phenotypic characteristics of tunisian isoniazid-resistant Mycobacterium tuberculosis strains

Forty three isoniazid (INH)-resistant Mycobacterium tuberculosis isolates were characterized on the basis of the most common INH associated mutations, katG315 and mabA -15C→T, and phenotypic properties (i.e. MIC of INH, resistance associated pattern, and catalase activity). Typing for resistance mutations was performed by Multiplex Allele-Specific PCR and sequencing reaction. Mutations at either codon were detected in 67.5% of isolates: katG315 in 37.2, mabA -15C→T in 27.9 and both of them in 2.4%, respectively. katG sequencing showed a G insertion at codon 325 detected in 2 strains and leading to amino acid change T326D which has not been previously reported. Distribution of each mutation, among the investigated strains, showed that katG S315T was associated with multiple-drug profile, high-level INH resistance and loss or decreased catalase activity; whereas the mabA -15C→T was more prevalent in mono-INH resistant isolates, but it was not only associated with a low-level INH resistance. It seems that determination of catalase activity aids in the detection of isolates for which MICs are high and could, in conjunction with molecular methods, provide rapid detection of most clinical INH-resistant strains.

Sequence and structural characterization of tbnat gene in isoniazid-resistant Mycobacterium tuberculosis: Identification of new mutations

The present study was carried out to investigate the presence of polymorphism in the N-acetyltransferase gene of 41 clinical isolates of Mycobacterium tuberculosis, that were resistant to isoniazid (INH) with no mutations in the hot spots of the genes previously described to be involved in INH resistance ( katG, inhA and ahpC). We observed single nucleotide polymorphisms (SNPs) in ten of these, including the G619A SNP in five isolates and an additional four so far un-described mutations in another five isolates. Among the latter SNPs, two were synonymous (C276T, n = 1 and C375G, n = 3), while two more non-synonymous SNPs were composed of C373A (Leu→Met) and T503G (Met→Arg) were observed in respectively one and two isolates. Molecular modeling and structural analysis based in a constructed full length 3D models of wild type TBNAT (TBNAT_H37Rv) and the isoforms (TBNAT_L125M and TBNAT_M168R) were also performed. The refined models show that, just as observed in human NATs, the carboxyl terminus extends deep within the folded enzyme, into close proximity to the buried catalytic triad. Analysis of tbnat that present non-synonymous mutations indicates that both substitutions are plausible to affect enzyme specificity or acetyl-CoA binding capacity. The results contribute to a better understanding of structure–function relationships of NATs. However, further investigation including INH-sensitive strains as a control group is needed to get better understanding of the possible role of these new mutations on tuberculosis control.

Genomic Stability over 9 Years of an Isoniazid Resistant Mycobacterium tuberculosis Outbreak Strain in Sweden

In molecular epidemiological studies of drug resistant Mycobacterium tuberculosis (TB) in Sweden a large outbreak of an isoniazid resistant strain was identified, involving 115 patients, mainly from the Horn of Africa. During the outbreak period, the genomic pattern of the outbreak strain has stayed virtually unchanged with regard to drug resistance, IS6110 restriction fragment length polymorphism and spoligotyping patterns. Here we present the complete genome sequence analyses of the index isolate and two isolates sampled nine years after the index case as well as experimental data on the virulence of this outbreak strain. Even though the strain has been present in the community for nine years and passaged between patients at least five times in-between the isolates, we only found four single nucleotide polymorphisms in one of the later isolates and a small (4 amino acids) deletion in the other compared to the index isolate. In contrast to many other evolutionarily successful outbreak lineages (e.g. the Beijing lineage) this outbreak strain appears to be genetically very stable yet evolutionarily successful in a low endemic country such as Sweden. These findings further illustrate that the rate of genomic variation in TB can be highly strain dependent, something that can have important implications for epidemiological studies as well as development of resistance.

A case of isoniazid-resistant miliary tuberculosis in which tuberculous meningitis paradoxically developed despite systemic improvement

A 63-year-old man with chronic myelomonocytic leukemia was admitted to our hospital with miliary tuberculosis. He received anti-tuberculosis drugs: isoniazid (INH), rifampicin (RFP), ethambutol (EB), and pyrazinamide (PZA). His condition clearly and immediately improved after the therapy, but he experienced a high fever of about 38°C every day from 1month after the initiation of the therapy. Drug-induced fever and tumor fever were suspected as causes, but the etiology could not be determined. The tuberculosis was identified as an INH-resistant strain, so INH was stopped and levofloxacin (LVFX) was introduced, with streptomycin (SM), in addition to RFP, EB, and PZA. At 2months after the initiation of the therapy (about one week after the change in the anti-tuberculosis drug regimen), his spinal fluid was examined, given his complaints of headache and vomiting. The spinal fluid analysis revealed invasion of lymphocytic inflammatory cells and high adenosine deaminase activity; the patient was thus diagnosed with tuberculous meningitis. His condition gradually improved after the changing of the anti-tuberculosis drugs. Thus, to summarize, the tuberculous meningitis had worsened paradoxically despite his systemic improvement, although it was successfully treated by the addition of LVFX and SM. We must keep in mind that a potential cause of fever during anti-tuberculosis therapy may be INH-resistant tuberculous meningitis.

Direct detection of isoniazid-resistant Mycobacterium tuberculosis in respiratory specimens by multiplex allele-specific polymerase chain reaction

This study evaluated the feasibility of using 2 multiplex allele-specific polymerase chain reaction (MAS-PCR) assays targeting 2 mutations (codon 315 of the katG gene and the 15th nucleotide preceding the mabA-inhA operon) to directly detect isoniazid (INH)-resistant Mycobacterium tuberculosis in cultured isolates and respiratory specimens. A total of 203 M. tuberculosis isolates and 487 respiratory specimens were investigated. The MAS-PCR assays successfully amplified all M. tuberculosis isolates and acid-fast bacilli smear-positive specimens while only 49.2% of the smear-negative specimens exhibited positive MAS-PCR results. The MAS-PCR assays identified 83.4% and 79.2% of the resistant strains in the culture isolates and respiratory specimens, respectively. All the inferred genotypes were in complete accordance with subsequent DNA sequence analyses. This study suggested the application of our improved MAS-PCR protocols to provide the rapid identification of INH-resistant M. tuberculosis directly in respiratory specimens. The technical simplicity, short turnaround time, and low cost of this molecular strategy should facilitate routine diagnostic services in developing areas with a high prevalence of drug-resistant tuberculosis.

Rifampin hypersensitivity in a two year-old child with successful rapid oral desensitization

A two year, 10 month-old child was referred to a tertiary allergy clinic following an adverse reaction to rifampin. Her mother had isoniazid-resistant pulmonary tuberculosis. The child was born in Canada, was asymptomatic, had a normal chest x-ray and liver enzymes. Mantoux induration was 17 mm. The child was prescribed oral rifampin, 150 mg per day for 3 months. Thirty minutes after ingesting the fifth dose, she developed swelling of the lips, eyes and face; and a pruritic rash to the extremities and face. Anti-histamine was administered: the rash resolved over thirty minutes and facial swelling over 2-3 hours. There were no other IgE-mediated symptoms. Rifampin was discontinued. Past history was negative for atopy, adverse drug reactions, and food allergies. Intravenous rifampin (600 mg/mL) was used for skin prick and intradermal testing. The patient was admitted to hospital and intravenous access established. Skin prick test results were negative to undiluted rifampin and saline; the histamine response was positive (5 mm). Intradermal testing was performed at 15-minute intervals with dilutions of 1:10,000, 1:1000 and 1:100. The 1:100 dilution test was positive. Rapid desensitization to oral rifampin was performed over 3.25 hours. The first dose was 1/10,000 of the total dose. Thirteen incremental doses were administered every 15 minutes until a cumulative dose of 151.08 mg had been ingested (Table 1). No adverse events were noted. The child was subsequently continued on a dose of oral rifampin 75 mg twice daily and has not had subsequent reactions. This case highlights the rare occurrence of rifampin hypersensitivity in a child. Desensitization was motivated by the lack of alternative therapies. Rifampin desensitization protocols preciously reported have occurred predominantly in the adult population over several days. We describe a case of rapid oral desensitization to rifampin in a two year-old child.

Isoniazid-resistant tuberculosis in Denmark: Mutations, transmission and treatment outcome

A retrospective study on isoniazid-resistant tuberculosis (TB) was conducted in the low-burden country, Denmark (DK). The aim was to describe treatment outcome and transmission and to evaluate a mutation analysis for high- and low-level isoniazid resistance detection. In the period 2002-2007, all isoniazid-resistant TB-cases were included. Molecular genotyping was performed by standardized IS6110 restriction fragment length polymorphism (RFLP). Identical isoniazid-resistant genotypes, indicating ongoing transmission, were identified from the national RFLP database. An analysis of rifampin (rpoB) and high- or low-level (katG, inhA) isoniazid resistance mutations was performed on subcultured strains. There were 1825 culture-confirmed cases, of which 111 (6.1%) had monoresistance or polyresistance to isoniazid. Successful short- and long-term treatment outcome was achieved in 80% and 95%, respectively. Overall, the mutation analysis predicted 94% of isoniazid resistance in 111 strains. The katG S315T1 and inhA C15T1 mutations correctly identified high- and low-level isoniazid resistance in 84% and 84% of the strains, respectively. Isoniazid-resistant TB has a good prognosis in DK. High- and low- level isoniazid resistance does not affect treatment outcome of standard modified treatment. Rapid mutation detection identified the majority of isoniazid-resistant cases however the impact on treatment outcome remains to be determined.

Extensive transmission of isoniazid resistant M. tuberculosis and its association with increased multidrug-resistant TB in two rural counties of eastern China: A molecular epidemiological study

BackgroundThe aim of this study was to investigate the molecular characteristics of isoniazid resistant Mycobacterium tuberculosis (MTB), as well as its contribution to the dissemination of multi-drug resistant TB (MDR-TB) in rural areas of eastern China.MethodsA population-based epidemiological study was conducted in two rural counties of eastern China from 2004 to 2005. In total, 131 isoniazid resistant MTB isolates were molecularly characterized by DNA sequencing and genotyped by IS6110 restriction fragment length polymorphism (RFLP) and spoligotyping.ResultsThe katG315Thr mutation was observed in 74 of 131 isoniazid resistant isolates and more likely to be MDR-TB (48.6%) and have mutations in rpoB gene (47.3%). Spoligotyping identified 80.2% of isoniazid resistant MTB isolates as belonging to the Beijing family. Cluster analysis by genotyping based on IS6110 RFLP, showed that 48.1% isoniazid resistant isolates were grouped into 26 clusters and katG315Thr mutants had a significantly higher clustering proportion compared to those with katG wild type (73%.vs.18%; OR, 12.70; 95%CI, 6.357-14.80). Thirty-one of the 53 MDR-TB isolates were observed in 19 clusters. Of these clusters, isoniazid resistance in MDR-TB isolates was all due to the katG315Thr mutation; 18 clusters also contained mono-isoniazid resistant and other isoniazid resistant isolates.ConclusionsThese results highlighted that isoniazid resistant MTB especially with katG315Thr is likely to be clustered in a community, develop extra resistance to rifampicin and become MDR-TB in Chinese rural settings.

Management of isoniazid-resistant pulmonary tuberculosis in patient with non-functioning bowel on the intensive care unit

A young Turkish woman presented with abdominal sepsis. Terminal ileal Crohn's disease was diagnosed on histology. She was treated with intravenous steroids and bowel resection but required multiple laparotomies for recurrent peritonitis. Isoniazid-resistant Mycobacterium tuberculosis was cultured from sputum. Treatment of tuberculosis was complicated by a long post-operative period of non-functioning bowel, which necessitated intravenous agents.