The combination of rifampin plus moxifloxacin is synergistic for suppression of resistance but antagonistic for cell kill of Mycobacterium tuberculosis as determined in a hollow-fiber infection model

G L Drusano, Nicole Sgambati, Adam Eichas, David L Brown, Robert Kulawy, Arnold Louie, G L Drusano, Nicole Sgambati, Adam Eichas, David L Brown, Robert Kulawy, Arnold Louie

Abstract

Moxifloxacin is under development for expanded use against Mycobacterium tuberculosis. Rifampin is a mainstay of therapy. We examined the interaction of moxifloxacin plus rifampin for log-phase and nonreplicating persister (NRP) organisms. For this evaluation, we employed our hollow-fiber infection model, in which organisms are exposed to clinically relevant drug concentration-time profiles and the impact on bacterial cell kill and resistant subpopulation amplification is determined. In log phase, resistance emergence was observed in all monotherapy regimens and in no combination therapy regimen. No difference was seen in time to a 3-log reduction in the bacterial burden; there was a significant difference in time to resistance emergence (P = 0.0006). In the NRP experiment, no resistance emergence was seen. There was a significant difference between the monotherapy and combination therapy regimens in time to a 3-log reduction in the bacterial burden (P = 0.042). The combination is efficacious for suppressing resistant organisms but is antagonistic for cell kill.

Figures

FIG 1
FIG 1
Effects of moxifloxacin alone and in combination on log-phase M. tuberculosis H37Ra. Panels: A, rifampin treatment; B, moxifloxacin treatment; C, 100 mg moxifloxacin in combination with three rifampin regimens; D, 200 mg moxifloxacin in combination with three rifampin regimens; E, 400 mg moxifloxacin in combination with three moxifloxacin regimens. Drug administrations were done once daily.
FIG 2
FIG 2
Emergence of resistance during drug administration. Panels: A, control; B, 300 mg rifampin QD; C, 600 mg rifampin QD; D, 200 mg moxifloxacin QD; E, 800 mg moxifloxacin QD; F, 200 mg moxifloxacin QD plus 100 mg rifampin QD.
FIG 3
FIG 3
Times to resistance emergence in M. tuberculosis H37Ra for single versus combination chemotherapy. The difference is significant (P = 0.0006; Breslow-Gahan test). Red is monotherapy arms. Blue is combination therapy arms.
FIG 4
FIG 4
Nile red staining of log-phase and NRP M. tuberculosis. (A) Organisms held in anaerobiosis for 28 days and thought to be in the Wayne-Hayes level II state. (Left) Organisms are visibly stained with Nile red. (Right) Organisms visualized by phase-contrast microscopy. (B) Organisms in log-phase growth. (Left) No staining visible with Nile red. (Right) Organisms visualized by phase-contrast microscopy.
FIG 5
FIG 5
Presence of 16-kDa α-crystalline protein, a proof of attainment of Wayne-Hayes level II anaerobiosis.
FIG 6
FIG 6
Effects of moxifloxacin alone and in combination on NRP-phase (Wayne-Hayes level II anaerobiosis) M. tuberculosis H37Ra. Panels: A, rifampin treatment; B, moxifloxacin treatment; C, 100 mg moxifloxacin in combination with three rifampin regimens; D, 200 mg moxifloxacin in combination with three rifampin regimens; E, 400 mg moxifloxacin in combination with three moxifloxacin regimens; F, effect of continuous infusion of isoniazid and continuous infusion of metronidazole. Drug administrations were done once daily.
FIG 7
FIG 7
Times to achievement of a 3-log kill of M. tuberculosis H37Ra cells in the NRP phase for single versus combination chemotherapy. The difference is significant (P = 0.042; Breslow-Gahan test). Red is monotherapy arms. Blue is combination therapy arms.

References

    1. Selkon J. B., Devadatta S., Mitchison D. A., Narayana A. S., Nair C. N., Ramachandran K. 1964. The emergence of isoniazid-resistant cultures in patients with pulmonary tuberculosis during treatment with isoniazid alone or isoniazid plus PAS. Bull. World Health Organ. 31:273–294
    1. Almeida D., Nuermberger E., Tasneen R., Rosenthal I., Tyagi S., Williams K., Peloquin C., Grosset J. 2009. Paradoxical effect of isoniazid on the activity of rifampin-pyrazinamide combination in a mouse model of tuberculosis. Antimicrob. Agents Chemother. 53:4178–4184
    1. Grosset J., Truffot-Pernot C., Lacroix C., Ji B. 1992. Antagonism between isoniazid and the combination pyrazinamide-rifampin against tuberculosis infection in mice. Antimicrob. Agents Chemother. 36:548–551
    1. Dickinson J. M., Aber V. R., Mitchison D. A. 1977. Bactericidal activity of streptomycin, isoniazid, rifampin, ethambutol, and pyrazinamide alone and in combination against Mycobacterium tuberculosis. Am. Rev. Respir. Dis. 116:637–635
    1. Wayne L. G., Hayes L. G. 1996. An in vitro model for sequential study of shiftdown of Mycobacterium tuberculosis through two stages of nonreplicating persistence. Infect. Immun. 64:2062–2069
    1. Garton N. J., Waddell S. J., Sherratt A. L., Lee S. M., Smith R. J., Senner C., Hinds J., Rajakumar K., Adegbola R. A., Besra G. S., Butcher P. D., Barer M. R. 2008. Cytological and transcript analyses reveal fat and lazy persister-like bacilli in tuberculous sputum. PLoS Med. 5:e75.
    1. Desjardin L. E., Hayes L. G., Sohaskey C. D., Wayne L. G., Eisenach K. D. 2001. Microaerophilic induction of the alpha-crystallin chaperone protein homologue (hspX) mRNA of Mycobacterium tuberculosis. J. Bacteriol. 183:5311–5316
    1. Blumberg H. M., Burman W. J., Chaisson R. E., Daley C. L., Etkind S. C., Friedman L. N., Fujiwara P., Grzemska M., Hopewell P. C., Iseman M. D., Jasmer R. M., Koppaka V., Menzies R. I., O’Brien R. J., Reves R. R., Reichman L. B., Simone P. M., Starke J. R., Vernon A. A. 2003. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am. J. Respir. Crit. Care Med. 167:603–662
    1. Wayne L. G., Hayes L. G. 1998. Nitrate reduction as a marker for hypoxic shiftdown of Mycobacterium tuberculosis. Tuber. Lung Dis. 79:127–132
    1. Greco W. R., Bravo G., Parsons J. C. 1995. The search for synergy: a critical review from a response surface perspective. Pharmacol. Rev. 47:331–385
    1. Drusano G. L., Liu W., Fregeau C., Kulawy R., Louie A. 2009. Differing effect of combination chemotherapy with meropenem and tobramycin on cell kill and suppression of resistance on wild-type Pseudomonas aeruginosa PA01 and its isogenic MexAB efflux pump-overexpressed mutant. Antimicrob. Agents Chemother. 53:2266–2273
    1. Gefen O., Gabay C., Municoglu M., Engel G., Balaban N. Q. 2008. Single cell protein induction dynamics reveals a period of vulnerability to antibiotics in persister bacteria. Proc. Natl. Acad. Sci. U. S. A. 105:6145–6149
    1. Dorman S. E., Johnson J. L., Goldberg S., Muzanye G., Padayatchi N., Bozeman L., Heilig C. M., Bernardo J., Choudhri S., Grosset J. H., Guy E., Guyadeen P., Leus M. C., Maltas G., Menzies D., Nuermberger E. L., Villarino M., Vernon A., Chaisson R. E., and the Tuberculosis Trials Consortium 2009. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am. J. Respir. Crit. Care Med. 180:273–280
    1. Conde M. B., Efron A., Loredo C., De Souza G. R., Graça N. P., Cezar M. C., Ram M., Chaudhary M. A., Bishai W. R., Kritski A. L., Chaisson R. E. 2009. Moxifloxacin versus ethambutol in the initial treatment of tuberculosis: a double-blind, randomised, controlled phase II trial. Lancet 373:1183–1189
    1. Yuan Y., Crane D. D., Barry C. E. 1996. Stationary phase-associated protein expression in Mycobacterium tuberculosis: function of the mycobacterial α-crystallin homolog. J. Bacteriol. 178:4484–4492
    1. Blaser J.1985. In-vitro model for simultaneous simulation of the serum kinetics of two drugs with different half-lives. J. Antimicrob. Chemother. 15Suppl. A: 125–130
    1. Clincial and Laboratory Standards Institute 2003. Susceptibility testing of mycobacteria, nocardiae, and other aerobic actinomycetes; approved standard. Clinical and Laboratory Standards Institute, Wayne, PA:

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