Resistance Mechanisms to Second Line Drug in Mycobacterium tuberculosis
Jabbar S. Hassan1 *, Thanaa R. Abdulrahman 2, Basim M. Hanon3
1, 2 College of Medicine, Al-Nahrain University, Baghdad, Iraq
3 College of Veterinary Medicine, University of Wasit, Wasit, Iraq
* Email of corresponding author: [email protected]
Abstract
Tuberculosis is one of the oldest and most dangerous diseases that humanity has faced, and scientists were able, through the discovery of many successful treatments, to neutralize its seriousness, but despite that, especially in poor countries, programs to control this disease did not succeed completely, and this led to the failure of most of the old treatments in eradicate this disease; Various types of drugs have been introduced onto the battlefield, but aminoglycosides in addition to fluroquinolones and their derivative drugs remain one of the most valuable weapons in this fight due to their ability to treat disease under various TB pathogenesis processes. This review offers a detailed summary of genetic mechanisms that lead to resistant to first line drug therapy used in management of Tuberculosis as well as up- to-date information on some new aspects lead to such problem.
Keywords: Mycobacterium tuberculosis, multi-drug resistant, Second line drug, anti-TB treatment, World Health Organization
Introduction
Tuberculosis (TB) is an ancient infection that has been known to affect humans. Its primary target organ is the lung, but it can spread to any tissue in the body. Every year, the death rate rises (1). According to the World Health Organization (WHO), about a quarter of the world's population has latent TB, which can be detected by a tuberculin skin test (2). Streptomycin, isoniazid, rifampicin, ethambutol, and pyrazinamide were used as first-line anti-TB drugs, while fluoroquinolones, amikacin, kanamycin, capreomycin, ethionamide, prothionamide, cycloserine, and para-amino salicylic acid were used as second-line anti-TB drugs (3). One of the most challenge in the control of Tuberculosis disease is the appearance of drug-resistant Mycobacterium tuberculosis strains, which include either unresponsiveness to first-line therapy, primarily isoniazid and rifampicin, and is known as Multidrug-resistant TB (MDR- TB), or pulse resistance to fluroquinolones such as levofloxacin or moxifloxacin, as well as resistance to at least one of the three injectable second-line drugs (amikacin, capreomycin or kanamycin), it refer to XDR-TB (3). Many fundamental risk factors may have contributed to
this troubled situation, such as mis-use of anti-TB drugs, treatment regimen failure, Tuberculosis relapse, difficulty getting a drug susceptibility testing (DTS), and in some countries' patients did not have easy access to drug supply (4).
Unfortunately, conventional culture methods using egg-yolk-enriched media are still the most commonly used techniques for TB-DST. However, the long time it takes to get a result for this traditional method irritates doctors in the management of TB cases, forcing doctors to treat newly diagnosed patients without using TB-DST. Despite the availability of newer methods for researching TB-DST, the high cost of such methods in low and middle-income countries prevents them from being used (4). The cell wall structure of Mycobacterium tuberculosis is complex and diverse, with a high lipid content that includes cord factor, mycolic lipid, and wax D. In addition, the cell envelope of Mycobacterium tuberculosis is extraordinarily hydrophobic and forms a remarkably strong permeability barrier, making it naturally resistant to antibiotics (5).
Resistance of tuberculosis bacteria to various treatments, particularly Isoniazid and Rifampicin, the most effective anti-TB drugs, has become a global issue, leading to an increase in the disease's morbidity and mortality (6). Mycobacterium tuberculosis uses two main genetic strategies to prevent and evade anti-TB therapy attacks. These genetic approaches include mutations in gene(s) that are often related to the mechanism of action of the compound, and the second strategy is horizontal gene transfer (HGT) to acquire DNA coding for resistance determinants (7).
Molecular construction of Mycobacterium tuberculosis
The chromosomal characteristic of Mycobacterium tuberculosis is 4,200,000 nucleotides long, with a G/C ratio of about 65 percent. This genome contains 4000 genes, and one of the most important genes in this genome is genes that code for lipid metabolism, which account for about 8% of the total genome makeup (8). Because the DNA homology between all Mycobacterium tuberculosis complex bacteria is 95-100 percent, and the 16S rRNA gene is found in all kinds of these bacteria, some researchers propose that this species be grouped as a single species (9). On the other hand, the l6S - 23S rRNA internal transcript spacer (ITS), which is a spacer DNA well used for mycobacteria species determination, has a high level of variation between species, both in base length and sequence, suggesting that mycobacterium species contain alleles in the ribosomal operon in their genome, implying that a significant amount of sequence variation exists (10).
Second-line drugs used in the fight against tuberculosis
The fight against Multidrug-resistant TB (MDR-TB) has been going on since ancient times, and it is still going on today. Various types of drugs have been introduced onto the battlefield, but aminoglycosides in addition to fluroquinolones and their derivative drugs remain one of the most valuable weapons in this fight due to their ability to treat disease under various TB pathogenesis processes (11). Effective tuberculosis therapy was first introduced in 1952, and since then, M. tuberculosis has become resistant to a variety of drugs used in both treatment and control programs. MDR and XDR-TB have arisen as a result of improper anti-TB medication use, incorrect prescriptions, low-quality drugs, and premature treatment termination (12). The treatment of tuberculosis differs significantly from that of other bacterial infections. Mycobacterium tuberculosis requires a long generation period and has the ability to remain dormant, resulting in reduced metabolic processing, making it a difficult therapeutic target (13). Furthermore, one of the most effective scape mechanisms in M.
tuberculosis is granuloma formations, which are composed of solid caseous material and make anti-TB penetration difficult, when the environmental pH is low enough to inhibit anti- TB therapeutic activity (14).
Drug resistance in M. tuberculosis
Mutation in genes, which leads to the impact or disruption of the work of drug-activating enzymes, is one of the most important strategies for developing drug resistance in Mycobacterium tuberculosis. These mutations may take the form of SNPs, insertions, or deletions, and to a lesser extent, large deletions. MTB Un-responses to drugs are not acquired by horizontal gene transfer by mobile genetic components, as is the case with other bacteria (15). MTB drug resistance is caused by two main mechanisms: primary drug resistance, which occurs when the bacteria is transmitted to a new host, and secondary drug resistance, which occurs when MTB acquires drug resistance mutations to one or more drugs (16).
Mechanisms of resistance Second-line injectable agents
Drug-resistant tuberculosis is currently treated with the aminoglycoside's kanamycin and amikacin, as well as the cyclic poly polypeptide capreomycin. Despite belonging to different antibiotic groups, all three drugs are protein synthesis inhibitors that function by binding to the bacterial ribosome and changing the structure of the 16S rRNA. Capreomycin resistance at a high level has been established; to mutations in the 1400 bp region of the rrs gene, and additional capreomycin resistance has been linked to tlyA gene polymorphisms. The rRNA
methyltransferase is necessary for ribose 20-O-methylation in rRNA, and this gene codes for it 90% (92.97%), (17).
The A–G polymorphism in the rrs gene 1401 is a common molecular mechanism of resistance to all this therapy, Capreomycin and amikacin resistance accounts for 70%–80% of global resistance, while kanamycin resistance accounts for 60% (18). Other resistance mechanisms related to kanamycin has been reported in last years; one of this mechanism is mutations in gene responsible for intracellular survival of Tuberculosis in macrophages this gene called eis gene (19). According to Zaunbrecher et al (2009), 80 % of clinical isolates with kanamycin resistance had genetic changes in the promoter region of this gene (20).
Fluoroquinolones
Fluoroquinolone is a type of antibiotic that has been used in recent years to fight bacterial infections and among the bacteria that have been used in its treatment are the tuberculosis bacteria. Ciprofloxacin and ofloxacin are belong to an older generation of Fluoroquinolones which originate from nalidixic acid; while Moxifloxacin and Gatifloxacin considered as Fluoroquinolone new generation and its new used as regimens for drug resistance Tuberculosis (21). The pharmacological actions of Fluoroquinolone based on targeting the DNA gyrase enzyme; thereby inhibited the DNA synthesis. So, the resistance to this antibiotic occurs when mutations in gyrA and gyrB genes are initiated because this genes code for DNA gyrases (22). Resistance to fluoroquinolones has been linked to mutations in the quinolone resistance-determining region, a conserved region of the gyrA and gyrB genes. In fluoroquinolone-resistant MTB strains, mutations in codons 90, 91, and 94 of the gyrA gene are the most common. Mutations in codons 74, 88, and 91 have also been related to fluoroquinolone resistance. Resistance to fluoroquinolones has also been related to efflux mechanisms (23).
Para-amino salicylic acid
The para-aminosalicylic acid (PAS) is the second therapy used for TB eradication after streptomycin then its abandoned; know this drug is re-used in treatments of Mycobacterium tuberculosis belong to the extensive drug resistance (XDR) (24). The actions of Para-amino salicylic acid based on changes the substrate of dihydropteroate synthase (DHPS/FolP1) which led to folate synthesis in MTB (25). Overexpression of RibD, an alternative enzyme with dihydrofolate reductase activity, confers resistance to PAS; resistance to this drug is also can be triggered by mutations in dihydrofolate synthase (FolC). Furthermore, loss-of-function mutations in the thymidylate synthase ThyA cause PAS resistance was also reported (26).
Ethionamide
Ethionamide is a prodrug activated by EthA, a flavin adenine dinucleotide (FAD)-containing NADPH- and O2-dependent Baeyer-Villiger monooxygenase (BVMO) role of EthA in M.
tuberculosis has not been fully elucidated but seems to involve modulation of cell wall composition. This is based on data showing that deletion of the ethA-ethR locus of Mycobacterium bovis BCG altered cell wall mycolic acid composition and increased adherence to host cells in vitro, a phenotype that can be modulated by cell wall components (27). The investigator remarked that expression of ethA gene which is EthA-encoding gene is controlled by a repressor under the TetR/CamR family of transcriptional regulators called EthR so, any mutation targeted this gene led to Ethionamide resistant. (28). However, other resistant pathway in ETH resistant M. tuberculosis clinical isolates, were also reported such as mutations in EthA gene, mshA gene play crucial role in the controlling of an enzyme essential to keto-mycolic acids syntheses (29). Nearly two hundred mutations in EthA have been reported in ETHR clinical isolates (30). A study has recently demonstrated the role of the mshA gene, encoding an enzyme essential to mycothiol biosynthesis as a target for ethionamide resistance using spontaneous isoniazid- and ethionamide-resistant mutants (31).
Mechanisms of resistance to new and repurposed drugs (Bedaquiline)
Bedaquiline occur belong to a class of therapy called diarylquinolines; which are approved for the treatment of tuberculosis, the effect of this treatment is directly toward atpE gene which encoded to an enzyme responsible for survival of mycobacterium tuberculosis in obligate aerobic condition called mycobacterial ATP synthase, for this reason Bedaquiline is very efficient against dormant type of tuberculosis (32). In addition to that new reported suggested that Bedaquiline also have an effective target against transcriptional repressor Rv0678 gene which controlled upregulation of efflux pumps in mycobacterium tuberculosis, as a result that lad to inhibition of adenosine 5'-triphosphate synthase (33). Target-based mutations in the atpE gene and Rv0678 gene have been related to high-level Bedaquiline resistance in mycobacterium tuberculosis (34).
Conclusion
From ancient times, tuberculosis bacteria were considered one of the pathogens that led to an increase in the number of morbidity and mortality throughout the world. The use of anti-TB drugs led to a decrease in the mortality rate and an increase in the number of people recovering from the disease Unfortunately, drug resistance increased significantly and it's a significant challenge for the successful control of the disease worldwide. Drug resistance was
not confined to the first line Anti-TB drug, but spread to include new types of antibiotics that used in eradicate or control tuberculosis disease Mycobacterium tuberculosis resistance to second line is caused by a variety of genetic and phenotypic mechanisms. Scientists can develop successful drugs as well as strategies through understanding the pathways for development Drug-resistant TB.
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