Genes associated with resistance to various anti‐TB drugs.
Abstract
Tuberculosis (TB) remains to be a serious health problem worldwide. There is an increased transmission of Mycobacterium tuberculosis strains with drug resistance, hence complicating TB control. The deciphering of the M. tuberculosis genome, together with the implementation of new molecular biology tools, has allowed the identification of changes in nucleic acid sequences with a functional impact. These mutations have become important in the design of early‐diagnostic kits to identify the resistance profile of M. tuberculosis. Since the conventional methods to determine the identity of M. tuberculosis strains based in cultures are laborious, time‐consuming and performed by specialized technicians, the result is generated until 4 months after receiving the samples. During this time, patients with TB are not adequately treated, and resistant strains may be transmitted to the rest of the population. In this chapter, we describe the most relevant mutations in genes associated with drug resistance in M. tuberculosis, the analysis of gene expression to identify new markers of drug resistance strains, and the development of new antituberculosis drugs against drug‐resistant strains.
Keywords
- Mycobacterium tuberculosis
- drug resistance
- mutations
- gene expression
- antituberculosis drugs
1. Introduction
Tuberculosis (TB) has remained a serious health problem since
2. Mutations that confer resistance in Mycobacterium tuberculosis
Although the rate of resistance to first and second line drugs in
Many works have revealed, using microbiological and clinical data, mutational events in clinical isolates from patients with tuberculosis. Multidrug resistance appears to result from the sequential acquisition of mutations. Possible reasons for the acquisition of mutations include inadequate prescription and delivery of chemotherapy, poor compliance, or an insufficient number of active drugs in the treatment regimen [11]. Mutations or combinations of mutations have been found in strains displaying single or multidrug resistance. Here, we summarized the most common mutation found in clinical isolates that confer resistance to the first and second line antituberculosis drugs (Table 1).
Drugs | MIC (µg/mL) | Drug mode of action | Gene | Target enzyme | Frequency of mutations (%) associated with resistance |
---|---|---|---|---|---|
Isoniazide | 0.02–0.2 | Inhibits mycolic acid synthesis and other multiple effects | Catalase peroxidase | 30–60 | |
Fatty acid enoyl acyl carrier protein reductase A | 70–80 | ||||
Alkyl hydroperoxidase reductase | Not known | ||||
β‐ketoacyl‐ACP synthase | Not known | ||||
NADH dehydrogenase | 9.5 | ||||
Rifampicin | 0.05–1 | Inhibits RNA synthesis | β subunit of RNA polymerase | 95 | |
Streptomycin | 2–8 | Inhibits protein synthesis | Ribosomal protein S12 | 65–67 | |
16S rRNA | |||||
7‐Methylguanosine methyltransferase | 33 | ||||
Ethambutol | 1–5 | Inhibits arabinogalactan synthesis | Arabinosyl transferase | 70–90 | |
Pyrazinamide | 16–100 | Disrupts plasmamembrane and energy metabolism (inhibits pantothenate and CoA synthesis) | Pyrazinamidase | >70 | |
Not known | |||||
Fluoroquinolones | 0.5–2.5 | Introduces negative supercoils in DNA molecules | DNA gyrase | 42‐85 | |
Kanamycin/Amikacin | 2–4 | Inhibits protein synthesis | 16S rRNA | >60 | |
Capreomycin/Viomycin | 2–4 | Inhibits protein synthesis | 16S rRNA | 40‐100 | |
rRNA methyltransferase | 80 | ||||
Ethionamide | 2.5–10 | Disrupts cell wall biosynthesis by inhibition of mycolic acid synthesis | Fatty acid enoyl acyl carrier protein reductase A | >60 | |
Flavin monooxygenase | >60 | ||||
Transcriptional repressor | Not known |
2.1. Isoniazid
Due to its properties as a bactericidal drug, isoniazid has been widely used as the first line drug in the treatment against
2.2. Rifampicin
Rifampicin is highly bactericidal for
2.3. Streptomycin
It has been considered as a second line antituberculosis drug, which binds to the 30S subunit of the ribosome and blocks protein synthesis. The resistance is provoked by mutations in the
2.4. Ethambutol
Ethambutol has a target, the inhibition of the enzyme arabinosyl transferase, which is involved in the biosynthesis of cell wall arabinogalactan. The enzyme is encoded by the embB gene, harboured in the embCAB operon, and mutation in this gene is related to ethambutol resistance. The most frequent mutation found in the
2.5. Pyrazinamide
This pro‐drug is converted to its active form, pyrazinoic acid, and it only kills non‐growing persistent bacteria. The mutations of the
2.6. Fluoroquinolones
Fluoroquinolones are able to inhibit the activity of DNA gyrase. When the activity of DNA gyrase is affected, the chromosomal DNA acquires a supercoiled conformation [17]. Then, mutations on
2.7. Amikacin/kanamycin
Amikacin and kanamycin are considered as second‐line antituberculosis drugs. It has been identified that the
2.8. Ethionamide
This prodrug requires to be activated by the mono‐oxygenase EtaA/EthA. It has been described as the only bactericidal agent against
Mutations described in
Within the rapid methods approved by the WHO, there are real‐time PCR‐based assays, as Xpert MTB/RIF, the line probe assays Genotype MTBDR
3. Searching for new markers to identify drug resistance of Mycobacterium tuberculosis
In the understanding and linking‐up of genetic associations with the drug resistance phenotype in
Locus | Symbola | Gene namea | Drug‐resistant phenotype | References |
---|---|---|---|---|
Antibiotic‐transport ATP‐binding protein ABC transporter | XDR | [32] | ||
Drug efflux membrane protein | XDR | [32] | ||
Daunorubicin‐dim‐transport ATP‐binding protein ABC transporter drrA | XDR | [32] [30] | ||
Daunorubicin‐dim‐transport membrane protein ABC transporter drrB | XDR | [32] [30] | ||
Phosphate‐transport ATP‐binding protein ABC transporter phoT | XDR | [31] | ||
Conserved membrane protein | MDR | [25] | ||
Membrane efflux protein efpA | MDR | [30] | ||
Conserved membrane transport protein | MDR | [30] | ||
MDR | [30] | |||
Aminoglycosides/tetracycline‐transport membrane protein | MDR | [30] | ||
Drug efflux membrane protein | MDR | [30] | ||
Conserved membrane protein | MDR | [30] | ||
Involved in transport of drug across the membrane (export) | MDR | [30] | ||
Conserved membrane transport protein | MDR | [30] |
Furthermore, studies in drug resistance strains have reported other genes as differentially expressed between sensitive and drug‐resistant strains. Functional categories of these genes are among others, stress response and translation (Table 3). On the other hand, expression of intergenic regions (IGs) has also been associated with a drug resistance phenomenon in
Locus | Symbola | Gene namea | Expression level modification | Drug‐resistant phenotype | References |
---|---|---|---|---|---|
Polyketide beta‐ketoacyl synthase pks4 | I | XDR | [31] | ||
Polyketide synthase associated protein papA3 | I | XDR | [31] | ||
Hypothetical exported protein | I | XDR | [31] | ||
Conserved hypothetical protein | I | XDR | [31] | ||
3‐oxoacyl‐[acyl‐carrier protein] reductase fabG1 | I | XDR | [31] | ||
Conserved hypothetical protein | I | XDR | [31] | ||
Membrane cytochrome D ubiquinol oxidase subunit I cydA | I | XDR | [31] | ||
Conserved lipoprotein | I | XDR | [31] | ||
Transcriptional regulator | I | XDR | [31] | ||
Conserved hypothetical protein | I | XDR | [31] | ||
Esat‐6 like protein esxG | I | MDR | [8] | ||
Low molecular weight protein antigen 7 esxH | I | MDR | [8] | ||
Esat‐6 like protein esxI | I | MDR | [8] | ||
50S ribosomal protein L35 rpmI | I | MDR | [8] | ||
30S ribosomal protein S1 rpsA | I | MDR | [8] | ||
Esterase/lipase lipF | R | MDR | [8] | ||
10 kda chaperonin groES | R | MDR | [8] | ||
Respiratory nitrate reductase alpha chain narG | R | MDR | [8] | ||
Drugs‐transport transmembrane ATP‐binding protein ABC transporter | R | MDR | [25] |
With the aim to demonstrate the resistance association between the level of expression of some genes and drug resistance, assays using recombinant strains of
4. Development of new drugs against Mycobacterium tuberculosis drug resistance strains
Even though tuberculosis antibiotic treatment therapy is described, drug resistance in
Drug therapy for a patient infected with a susceptible
Because the problem of resistant tuberculosis is increasing, searching for new drugs continues with the aim of improving the therapeutic regimens currently used, shorten treatment duration in addition to find more effective drugs for latent TB and drug‐resistant strains. The development of new antituberculosis drugs implicates the following stages: basic research, discovery of new antituberculosis compounds or drugs, preclinical and clinical studies conformed by phases I, II, and III to finally get to the technology transfer; all these processes entail long periods of time [37]. In this continuous search for better antituberculosis drugs, many natural, semi‐synthetic, and synthetic compounds have been evaluated
As general conclusion, although mutations are commonly associated with drug resistance in
Acknowledgments
This work was partially supported by Instituto Mexicano del Seguro Social (FIS/IMSS/PROT/G15/1457).
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