Documente Academic
Documente Profesional
Documente Cultură
PRESENTED
BY
OGBU JASON CHETA
DE;2013/2993
OPTION: MEDICAL MICROBIOLOGY
A SEMINAR SUBMITTED TO THE DEPARTMENT OF
MEDICAL LABORATORY SCIENCE IN PARTIAL
FULFILMENT OF THE REQUIREMENT FOR THE
AWARD OF BACHELOR OF MEDICAL LABORATORY
SCIENCE(BMLS)DEGREE FACULTY OF SCIENCE,
DEPARTMENT OF MEDICAL LABORATORY
SCIENCE, RIVERS STATE UNIVERSITY OF SCIENCE
AND TECHNOLOGY ,NKPOLU-OROWORUKWO,
P.M.B. 5080, PORT HARCOURT
SUPERVISOR:DR.(MRS)WOKEM, G.N
MARCH, 2016
DEDICATION
I dedicate this research work to my parents,Mr & Mrs C.A Ogbu and my brother Mr Patrick
Ogbu
ACKNOWLEDGMENT
My profound gratitude goes to the almighty God,His son Jesus Christ(Our Saviour0 and the
Holy spirit,for giving me wisdom,knowledge,understanding and good healthnof mind and
body before and during the period of my seminar research.
Am highly indebted to all the researchers and writers to whom materials I have use in the
writing of this seminar and Google for providing an easy platform for information retrieval.
Final thanks goes to my friends and classmates for their advice and information in the course
of writing and typesetting this work
SUMMARY
The use of antibiotics in the management of tuberculosis has been a double-edged knife. Despite the fact that
they destroy the Mycobacterium tuberculosis, they also show drug resistance against the bacteria indicating
ineffectiveness. Worldwide surveillance has depicted that drug resistant tuberculosis is widespread and is
recently a menace to tuberculosis control programs in many countries. The use of molecular techniques like the
GeneXpert and Line Probe Assays, during the last few years has greatly changed our understanding of drug
resistance in tuberculosis. The arrival of HIV/AIDS in the 1980s resulted in an increase in transmission of TB
associated with outbreaks of multidrug-resistant Tuberculosis,that is resistant to isoniazid and rifampin. In this
paper, a discuss on the challenges associated with the control of Mycobacterium tuberculosis drug resistance,
and an update on recent diagnostic and drug regimen in the management of the disease, within the context of the
new public health, as it refers to the ways in which health systems manage and monitor threats to public health.
TABLE OF CONTENT
CHAPTER ONE
1.0 Introduction
1.1 Scientific classification
1.2 Historical perspective of tuberculosis
1.3 Mode of transmission
1.4 Symptoms and associated risk factors
1.4.1 Tuberculosis disease risk factors
1.5 Diagnostic methods of Tuberculosis
1.5.1 WHO- recommended diagnostic technique
CHAPTER TWO
2.0 Evolution of drug resistance and global surveillance
2.1 Molecular mechanism of drug resistance in Mycobacterium tuberculosis
2.2 First line drugs for TB
2.3 Second line drugs for TB
2.4 Newly introduced drugs in treating TB
CHAPTER THREE
3.0 Challenges to public health and health administrators
3.1 Management of Tuberculosis
Conclusion and recommendation
CHAPTER 1
INTRODUCTION
Tuberculosis is a potentially fatal contagious disease that can affect almost any part of the
body but is mainly an infection of the lungs. It is caused by a bacterial microorganism, the
very closely related mycobacterial species (M. bovis, M. africanum, M. microti, M. pinnipedi,
M. canetti, M. caprae and M. mungi) together comprise what is known as the M. tuberculosis
complex.
worldwide. According to the latest World Health Organization (WHO) report, there were an
estimated 8.6 million incident cases of TB in 2012 and 1.3 million deaths were attributed to
the disease. More than half a million cases occurred in children and 320,000 deaths were
Kingdom :- Bacteria
Phylum :- Actinobacteria
Class :- Actinobacteria
Order :- Actinomycetales
Suborder :- Corynebacterineae
Family :- Mycobacteriaceae
Genus :- Mycobacterium
Species :- M. tuberculosis
Consumption, phthisis, potts disease and the white plague are all terms used to refer to
literature around 460 B.C. Hippocrates identified the illness as the most common cause of
Galen, the most eminent Greek physician after Hippocrates, defined phthisis as the
ulceration of the lungs, thorax or throat, accompanied by a cough, fever and consumption of
The tuberculosis epidemic in Europe, which probably started in the 17th century and which
lasted two hundred years, was known as the great white plague. Death by tuberculosis was
considered inevitable and it was the principal cause of death in the mid-17th century. The high
population density, as well as the poor sanitary conditions that characterized most European
and North American cities at that time created perfect environment for its propagation.
In the nineteenth century, precisely on March 24,1882, the microbiologist Robert Koch
announced to the Berlin physiological society that he had discovered the cause of
tuberculosis. Because antibiotics were unknown at that time, the only means of controlling
the spread of infection was to isolate patients in private hospitals limited to patients with TB,
which is known as TB sanatorium a practice that continues to this day in some countries.
During the early 1940s, streptomycin, the first antibiotic effective against Mycobacterium
tuberculosis was discovered, then the infection began to come under control. Although their
was an upsurge in the disease in the late twentieth century due to the HIV/AIDS epidemic.
AIDS patients are much more likely to develop tuberculosis because of weakened immune
system.
even shouts, and are released into the air. This mist or aerosol as it is often called can be
taken into the nasal passages and lungs of a susceptible person nearby. Depending on the
environment, these tiny particles can remain suspended in the air for several hours. Unlike
many other infections, TB is not transmitted by surface contact with a patients clothing, bed
linens or dishes and cooking utensils. The most important exception is in pregnancy. The
foetus of an infected mother may contract TB by inhaling or swallowing the bacilli in the
amniotic fluid.
There are two types of tuberculosis conditions: (i)Latent tuberculosis infection(LTBI) and (ii)
Tuberculosis disease. Persons with latent tuberculosis infection have the M. tuberculosis in
their bodies, but do not have the disease or make such persons sick and cannot spread the
In some people, the tubercle bacilli overcome the immune system and multiply, resulting in
who have TB disease are usually infectious and may spread the bacteria to other people.
The symptoms of the disease include:-
* No appetite
* Sweating at night
Anyone can get TB, but persons at high risk generally fall into several categories:-
* People with medical conditions that weaken the immune system (immunocompromised),for
instance: persons with HIV infection has a very high risk of developing TB disease, HIV and
tuberculosis are so closely connected that there relationship is often described as a co-
epidemic.
testing, potential for high throughput and fewer requirements for laboratory biosafety. The
development of the Xpert MTB/RIF assay for the Gene-Xpert platform was completed in
Ziehl-Neelsen(ZN) light microscopy performed directly on sputum has been the primary
diagnostic technique for over 100years, and is suitable for all laboratory service levels,
mercury vapour lamps as light sources. A lower magnification objective is used to scan
smears allowing a much larger area of the smear to be seen and therefore taking less time
susceptibility).
resistance against individual drugs. DST is essential for identifying patients at risk of MDR-
*Molecular testing:
resistance have been endorsed by WHO in 2008 with detail policy guidance on its
introduction at country level. The amplification of nucleic acids (DNA or RNA) for the
diagnosis of TB or to detect drug resistance is a sensitive method that can produce faster
results than conventional culture methods. Polymerase chain reaction (PCR) is the most
cartridge that contains all reagents required for the detection of M. tuberculosis and
rifampicin resistance with PCR. Rifampicin resistance is an indicator of MDR-TB. The Xpert
MTB/RIF cartridge uses Cepheids fully automatic GeneXpert device. The assay can be
performed directly on a sputum sample. The test has similar sensitivity to culture, is specific
Fig 1.3
A Med Lab. Scientist using GeneXpert machine.
Source..WHO,2013
CHAPTER TWO
Drug resistance has being a major issue in the treatment of tuberculosis cases, which has
is defined as resistance in invitro to at least isoniazid and rifampicin, while Extensively drug-
resistant (XDR-TB) is resistant to at least one fluoroquinolone and one injectable second line
et.al.,2006).
Shortly after the first anti-tuberculosis (TB) drugs were introduced, streptomycin(STR), para-
measure resistance accurately and easily. By the end of the 1960s rifampicin(RIF) was
introduced and with the use of combination therapy, there was a decline in funding and
carried out for the following 20 years. The arrival of HIV/AIDS in the 1980s resulted in an
al.,1992) i.e resistant to INH and RIF. In the early 1990s drug resistance surveillance was
resumed in developed countries, but the true incidence remained unclear in the developing
world.
Since 2005, the worldwide incidence rate has dropped slowly. In 2011, an estimated 8.7
million cases occurred globally including 1.1 million cases among the HIV-infected
population. The global incidence rate is 125 cases per 100 000 population. The 22 high-
burden countries account for 82% of the global TB burden(WHO,2012). These countries are
all low-and-middle-income countries (LMIC) and the incidence rates in 14 of these countries
are declining, six countries have stable rates and two countries have an increasing TB
incidence rate. The number of TB deaths was approximately 1.4 million in 2011. Globally the
Since the 2004 Priority Medicines report the world has seen an increase in the incidence of
M. tuberculosis resistant to first-line drugs (Multi-Drug Resistant TB; MDR-TB) and the
countries (e.g. Italy, Iran and India), reported TB strains with severe patterns of drug
resistance. The term Totally-Drug Resistant TB is used for these TB strains, but has not
Global trends in MDR-TB rates are unclear due to the lack of data in several countries.
Combined data showed that on average multidrug resistance occurs in 3.4% and 19.8% of
new and previously treated TB cases respectively(WHO 2010). Countries with a high burden
of MDR-TB cases in Europe include Estonia, Lithuania, Moldova and Belarus. Data on
XDR-TB are much scarcer, but globally approximately 9.4% of all MDR-TB cases were
extensively drug resistant with high burdens in Estonia, Latvia, South Africa and
Tajikistan(WHO,2010).
At least one-third of the worlds HIV-positive population is infected with TB. Co-infected
TB/HIV patients are 21-34 times more likely to develop active TB than those living solely
people. In 2010, 350,000 people died due to HIV-associated TB(WHO,2010). For HIV-
positive TB patients, it is crucial to detect MDR as soon as possible due to their high risk of
mortality. Mortality rates can exceed 90% in patients co-infected with XDR-TB and HIV
(WHO, 2013).
2.1 Molecular mechanism of drug resistance in Mycobacterium tuberculosis
In order to control the drug resistance epidemic it is necessary to gain insight into how M.
tuberculosis develops drug resistance. This knowledge will help us to understand how to
prevent the occurrence of drug resistance as well as identifying genes associated with drug
resistance of new drugs. Mutations in the genome of M. tuberculosis that can confer
resistance to anti-TB drugs occur spontaneously with an estimated frequency of 3.5 10-6 for
INH and 3.1 10-8 for RIF. Because the chromosomal loci responsible for resistance to
various drugs are not linked, the risk of a double spontaneous mutation is extremely low: 9
2.2.1 Rifampicin
of the most effective anti-TB antibiotics and together with isoniazid makes up the basis of
the multidrug treatment regimen for TB. Rifampicin is active against growing and non-
clinical isolates of M. tuberculosis harbor mutations in the rpoB gene that codes for the -
subunit of the RNA polymerase. As a result of this, conformational changes occur that
decrease the affinity for the drug and results in the development of resistance. In about 96%
of M. tuberculosis isolates resistant to rifampicin, there are mutations in the so-called hot-
spot region of 81-(base polar)bp spanning codons 507533 of the rpoB gene. This region is
2.2.2 Isoniazid
Isoniazid was introduced in 1952 as an anti-TB agent and it remains, together with
rifampicin, as the basis for the treatment of the disease. Unlike rifampicin, isoniazid is only
KatG, encoded by the katG gene, to exert its effect (Zhang et al,1992). Isoniazid acts by
inhibiting the synthesis of mycolic acids through the NADH-dependent enoyl-acyl carrier
structure, resistance to this drug has been associated with mutations in several genes, such as
The two main molecular mechanisms of isoniazid resistance are associated with gene
mutations in katG and inhA or its promoter region. Indeed, numerous studies have found
mutations in these two genes as the most commonly associated with isoniazid
resistance to reactive oxygen intermediates and it was initially proposed that mutations in the
promoter of ahpC could be used as proxy markers for isoniazid resistance(Rinder et al,1998).
It is now better understood that mutations in the promoter of ahpC are compensatory
mutations for the loss of catalase/peroxidase activity rather than the cause for isoniazid
resistance. However, the role of kasA mutations in isoniazid resistance is presently unclear,
because similar mutations were also found in isoniazid-suscetible isolates , and, in cases of
2.2.3 Ethambutol
Ethambutol was first introduced in the treatment of TB in 1966 and is part of the current first-
line regimen to treat the disease. Ethambutol is bacteriostatic against multiplying bacilli
Recognized mechanism of resistance to ethambutol has been linked to mutations in the gene
embB. Moreover, a study with a large number of M. tuberculosis isolates found that
mutations in embB306 were not necessarily associated with resistance to ethambutol but with
transmitted(Hazbon et al,2005). These findings could have influence on the correct detection
of ethambutol resistance by current molecular methods. There remain about 30% ethambutol
resistant strains that do not present any mutation in embB stressing the need to identify other
2.2.4 Pyrazinamide
Pyrazinamide was introduced into TB treatment in the early 1950s and constitutes now part
nicotinamide and its introduction allowed reducing the length of treatment to six months. It
has the characteristic of inhibiting semi-dormant bacilli residing in acidic environments such
coded by the pncA gene. The proposed mechanism of action of pyrazinamide involves
energetics inhibiting membrane transport. Pyrazinamide would enter the bacterial cell by
passive diffusion and after conversion to pyrazinoic acid it is excreted by a weak efflux
pump. Under acid conditions, the protonated pyrazinoic acid would be reabsorbed into the
cell and accumulated inside, due to an inefficient efflux pump, resulting in cellular
damage(Zhang, 2005).
A recent study, however, has challenged the previous model by proposing that pyrazinoic
al,2007) .
Mutations in the gene pncA remain as the most common finding in pyrazinamide resistant
strains. Some few studies have reported the occurrence of pyrazinamide resistant strains
without any mutation in pncA stating that the resistance could be due to mutations in another
not yet identified regulatory gene(Cheng et al, 2004). Based on the current evidence, the
al,2013)
2.2.5 Streptomycin
Originally isolated from the soil microorganism Streptomyces griseus, streptomycin was the
actively growing bacilli and its mode of action is by inhibiting the initiation of the translation
in the protein synthesis(Moazed & Noller,1987). More specifically, streptomycin acts at the
level of the 30S subunit of the ribosome at the ribosomal protein S12 and the 16S rRNA
Consequently, mutations in rpsL and rrs are the major mechanisms of resistance to
streptomycin but account for 60%70% of the resistance found(Gillespie,2002). There are an
important percentage of strains resistant to streptomycin that lack mutations in either of these
According to the WHO the following drugs can be classified as second line drugs:
Unfortunately,second-line drugs are inherently more toxic and less effective than first line-
line drugs(WHO,2010). Second line drugs are mostly used in the treatment of MDR-TB and
Fluoroquinolones are currently in use as second-line drugs in the treatment of MDR-TB. Both
ciprofloxacin and ofloxacin are synthetic derivatives of the parent compound nalidixic acid,
generation quinolones such as moxifloxacin and gatifloxacin are being evaluated in clinical
trials and proposed as first-line antibiotics with the purpose of shortening the length of
and topoisomerase IV, two critical enzymes for bacterial viability. These proteins are
encoded by the genes gyrA, gyrB, parC and parE, respectively (Fabrega et al,2009). In M.
tuberculosis, only type II topoisomerase (DNA gyrase) is present and, thus, is the only target
two and subunits, coded by gyrA and gyrB, respectively, which catalyzes the supercoiling
al,2012).
acknowledged the presence of strains resistant to gatifloxacin and moxifloxacin that were still
tuberculosis(Escribano et al,2007).
2.3.2 Aminoglycosides
synthesis and thus cannot be used against dormant M. tuberculosis. Aminoglycosides bind to
bacterial ribosomes and disturb the elongation of the peptide chain in the bacteria. Mutations
in the rrs gene encoding for 16s rRNA are associated with resistance to KAN and AMI.
Nucleotide changes at positions 1400,1401 and 1483 of the rrs gene have been found to be
2.3.3 Ethionamide
with the mycolic acid synthesis by forming an adduct with NAD that inhibits the enoyl-ACP
reductase enzyme. Resistance to ethionamide occurs by mutations in etaA/ethA, ethR and also
2.3.4 Cycloserine
alanine ligase inhibits the synthesis of peptidoglycan. It can also inhibit D-alanine racemase
(AlrA) needed for the conversion of L-alanine to D-alanine(Zhang,2005). Although the actual
recombinant mutants(Caceres et al,1997) . More recently, it has also been shown that a point
mutation in cycA, which encodes a D-alanine transporter, was partially responsible for
2.3.5 Thioacetazone
Thioacetazone is an old drug that was used in the treatment of TB due to its favourable in
vitro activity against M. tuberculosis and its very low cost. It has toxicity problems, however,
especially in patients co-infected with HIV. It belongs to the group 5 drugs of the WHO and
Notwithstanding the alleged lack of interest of the pharmaceutical industry for the
development of new antibiotics, there are several anti-tuberculosis drugs in the pipeline and
some of them are already being evaluated in clinical trials and in new combinations with the
2.4.1 Bedaquiline
class of diarylquinolines with specific activity against M. tuberculosis, which has also shown
vitro and in vivo activity against M. tuberculosis and then entered into clinical evaluation for
drug susceptible and MDR-TB. Based on the results of two phase II clinical trials,
bedaquiline has recently received conditional approval for the treatment of MDR-TB under
the trade name Sirturo. Recent reviews and evaluation of this new drug have been published
(Chahine et al, 2014). A phase III clinical trial was scheduled to begin in 2013 but has not yet
started. Bedaquiline is also being evaluated in new combination regimens with the purpose of
which was a completely new target of action for an antimycobacterial drug. This mode of
The results of two trials (phase II) suggested that a standard 2-month treatment regimen with
bedaquiline yielded high culture conversion rates, rapid sputum culture conversion and low
al,2012) .
2.4.2 Delamanid
imidazooxazole with activity against M. tuberculosis that acts by inhibiting the synthesis of
mycolic acid and is undergoing clinical evaluation in a phase III trial(Palomino and
Martin,2013). Delamanid was previously shown to have a very good in vitro and in vivo
al,2011). Delamanid at present has shown its safety and efficacy in a clinical management for
MDR-TB. The specific mode of action of delamanid is by inhibition of the mycolic acid
synthesis but it differs from isoniazid in that, it only inhibits methoxy- and keto-mycolic acid
Rv3547 gene, suggesting its role in the activation of the drug(Matsumoto et al,2006).
2.4.3 SQ-109
Compound SQ-109 is a synthetic equivalent but independent type of ethambutol that has
activity when combined with first-line drugs, and more interestingly, when combined with
bedaquiline and the oxazolidinone PNU-10048(Reddy et al,2010). The mode of action of SQ-
109 is by interfering with the assembly of mycolic acids into the bacterial cell wall core,
dimycolate. Transcriptional studies have shown that, similar to other cell wall inhibitors such
as isoniazid and ethambutol, SQ-109 induces the transcription of the iniBAC operon required
2.4.4 Benzothiazinones
(BTZ043) was found to have in vitro, ex vivo and in vivo activity against M. tuberculosis. It
was also found to be active against drug-susceptible and MDR clinical isolates of M.
By transcriptome analysis, the mode of action of BTZ043 was initially spotted at the cell wall
biogenesis level. By further genetic analysis, using in vitro generated mutants, the target of
the drug was identified at the level of the gene rv3790, which together with rv3791 encode
decaprenylphosphoryl arabinose (DPA), a precursor for arabinan synthesis needed for the
bacterial cell wall(Mikusova, 2005). DprE1 and DprE2 were proposed as names for these two
able to reduce the drug, this finding could be important for development of new BTZ
Mortality due to infectious disease has fallen dramatically in the past centuries as a result of
sanitary and food safety development along with vaccines, antibiotics and other advances in
societal conditions and medical sciences. However, the challenges of population growth,
populations have been associated with a shift in geographical distribution and accelerated
The health, social, economic, and political consequences associated with these emerging
diseases are still significant to public health. In the context of the New Public Health, they are
still central issues because of the enormous unfulfilled potential to reduce morbidity and
mortality globally. The public health community has learned much about facing new
Global anticipation of the most recent TB epidemic has required international, national and
local health authorities to undertake extensive preparation. Despite the preparation, public
awareness and acceptance of immunization were insufficient and the pandemic eventually
faded from public view by itself. Hence, much effort is still needed to better understand the
biological mechanisms of HIV transmission and diffusion as well as peoples
behaviours/attitudes in the face of risk before we can hope to better combat tomorrows
New knowledge concerning micronutrients, oral disease and infectious diseases will become
part of public health methodology. New methods of producing vaccines against infectious
agents like Tuberculosis will bring huge public health gains in the coming decades, but the
urgency is great for new vaccines, such as that for Tuberculosis. Infections are unequally
spread and unpredictably transferred around the world. Rapid mass transportation and human
mobility helps introduce and spread organisms to previously unexposed populations, which
can then become resistant to treatments available, thus, rendering the disease Tuberculosis
Optimism but not complacency is justified. Political and financial support is needed to
maintain and develop the gains achieved in the past century and to transmit the latest
knowledge and technology to many parts of the world where preventable deaths measure in
the hundreds of thousands. The New Public Health calls for fair distribution of resources and
the timely application of existing knowledge and tools; funding ,initiative and training, all
General measures such as avoidance of overcrowded and unsanitary conditions are also
necessary aspects of prevention. Hospital emergency rooms and similar locations can be
3.1.1 Vaccination
Vaccination is one major preventive measure against TB. A vaccine called BCG(Bacillus
Mycobacterium that infects cattle. Vaccination with BCG does not prevent infection by M.
tuberculosis but it does strengthen the immune system of first-time TB patients. As a result,
serious complications are less likely to develop. BCG is used more widely in developing
countries. The effectiveness of vaccination is still being studied, it is not clear whether the
formulation.
susceptibility testing and second-line agents are usually insufficient. Most national TB-
control programs endorse algorithms for treating patients whose infections fail to respond to
treatment that rely on the addition of new line drugs to the standard first/second-line
regimen.In settings with limited amounts of MDR-TB, these algorithms may be appropriate.
levels of resistance by selecting for additional mutants during therapy. Rational MDR-TB
susceptible (e.g., pyrazinamide) plus the addition of one drug from group 4(cycloserine or
ethionamide).
WHO in all cases and particularly for those previously treated(Falzon et al,2013). While
awaiting DST results, in settings with a medium or low probability of MDR-TB, retreatment
cases could initially be treated with an empiric regimen including isoniazid, rifampicin,
pyrazinamide and ethambutol for 1 month, and isoniazid, rifampicin, and ethambutol for 5
months.
Isoniazid can be given for the prevention as well as the treatment of TB. Isoniazid is
effective when given daily over a period of 6 to 12 months to people in high-risk categories.
Isoniazid appears to be most beneficial to persons under the age of 25. Because isoniazid
carries the risk of side-effects(liver inflammation, nerve damage, changes in mood and
CONCLUSION
Drug resistance is a worldwide problem that threatens to undermine effective control of TB.
regions with weak TB-control programs and misuse of anti-TB drugs. Prevention of drug
resistance depends on appropriate treatment of all patients with TB with combination drug
regimens and early detection of resistance followed by tailored treatment with second-line
agents and most recent, the newly introduced drugs. In countries with low levels of MDR-
TB, efforts should be concentrated on preventing acquired MDR-TB by endorsing and widely
implementing the WHO DOT strategy. In regions with high levels of MDR-TB, although
susceptibility testing. In countries with limited resources, more operational research is needed
to define the best cost-effective strategies for individual as against standardized patient
management of MDR-TB under national program conditions. The ultimate goals are
provision of timely, appropriate, and adequate services. These must be provided, and
continually evaluated and updated. A highly infectious tuberculosis patient must have access
to state-of-the-art laboratory services, even if the patient resides in an area where a local
laboratory is not capable of providing those services. Also coordinated efforts to monitor and
prevent misuse of antibiotics are crucial to reducing the spread of microbial resistance, which
can arise due to factors such as self medication, prescription of antibiotics for viral infections
Recommendation
(WHO, 2013)
AMI :-Aminokacin
DCS :-D-cycloserine
ETH :-Ethionamide
EMB :-Ethambutol
INH :-Isoniazid
KAN :-Kanamycin
STR :- Streptomycin
Andries K, Verhasselt P, Guillemont J,(2005). A diarylquinoline drug active on the ATP synthase of
Mycobacterium tuberculosis. Science. 307(9), 223227.
Andries, K.; Verhasselt, P.; Guillemont, J.; Ghlmann, H.W.; Neefs, J.M.; Winkler, H.; van Gestel, J.;
Timmerman, P.; Zhu, M.; Lee, E.(2005). A diarylquinoline drug active on the ATP synthase of
Mycobacterium tuberculosis. Science 30(7), 223227.
Aubry, A.; Pan, X.S.; Fisher, L.M.; Jarlier, V.,and Cambau, E.(2004). Mycobacterium tuberculosis
DNA gyrase: Interaction with quinolones and correlation with antimycobacterial drug activity.
Journal of Antimicrobial Agents and Chemotherapy, 48(9), 12811288.
Barnes, D.S. (1995). The Making of a Social Disease: Tuberculosis in Nineteenth-century France.
Retrieved from http://www.amazon.com/books/content/ (Retrieved 7 February,2016).
Boshoff, H.I.; Myers, T.G.; Copp, B.R.; McNeil, M.R.; Wilson, M.A.; Barry, C.E.(2004). The
transcriptional responses of Mycobacterium tuberculosis to inhibitors of metabolism: Novel
insights into drug mechanisms of action. Journal of Biological Chemistry. 279(2), 40174
40184.
Bourdelais, Patrice; Bart K. Holland (2006). Epidemics Laid Low: A History of what Happened in
rich Countries. JHU Press. ISBN 080188294X.
Brossier, F.; Veziris, N.; Truffot-Pernot, C.; Jarlier, V.; Sougakoff, W.(2011) Molecular investigation
of resistance to the antituberculous drug ethionamide in multidrug-resistant clinical isolates of
Mycobacterium tuberculosis. Antimicrobial Agents Chemotherapy 55, 355560.
Cceres, N.E., Harris, N.B., Wellehan, J.F., Feng, Z., Kapur, V., Barletta, R.G.(1997). Overexpression
of the D-alanine racemase gene confers resistance to D-cycloserine in Mycobacterium
smegmatis. Journal of Bacteriology 179, 50465055.
Crofton, J.; Mitchison, D.A.(1948) Streptomycin resistance in pulmonary tuberculosis. British
Medical Journal 2(5), 10091015.
Cheng, A.F.; Yew, W.W.; Chan, E.W.; Chin, M.L.; Hui, M.M.; Chan, R.C(2004). Multiplex PCR
amplimer conformation analysis for rapid detection of gyrA mutations in fluoroquinolone-
resistant Mycobacterium tuberculosis clinical isolates. Journal of Antimicrobial Agents
Chemotherapy 48(4), 596601.
Chen, J.M.; Uplekar, S.; Gordon, S.V.; Cole, S.T.(2012). A point mutation in cycA partially
contributes to the D-cycloserine resistance trait of Mycobacterium bovis BCG vaccine strains.
PLoS One 7, e43467.
Chahine, E.B.; Karaoui, L.R.; Mansour, H.(2014). Bedaquiline: A novel diarylquinoline for
multidrug-resistant tuberculosis. Annals of Pharmacotherapy, 48(8), 107115.
Caws, M.; Duy, P.M.; Tho, D.Q.; Lan, N.T.; Hoa, D.V.; Farrar, J(2006). Mutations prevalent among
rifampin and isoniazid-resistant Mycobacterium tuberculosis isolates from a hospital in
Vietnam. Journal of Clinical Microbiology, 44, 23332337.
DeBarber, A.E.; Mdluli, K.; Bosman, M.; Bekker, L.G.; Barry, C.E.(2000) 3rd. Ethionamide
activation and sensitivity in multidrug-resistant Mycobacterium tuberculosis. Proc. National
Academic of Science. USA 97, 96779782.
Diacon, A.H.; Dawson, R.; Hanekom, M.; Narunsky, K.; Venter, A.; Hittel, N.L.; Geiter, J.; Wells,
C.D.; Paccaly, A.J.; Donald, P.R.(2011). Early bactericidal activity of delamanid (OPC-67683)
in smear-positive pulmonary tuberculosis patients. International Journal on Tuberculosis and
Lung Disease, 15(6), 949954.
Diacon, A.H.; Dawson, R.; du Bois, J.; Narunsky, K.; Venter, A.; Donald, P.R.; van Niekerk, C.;
Erondu, N.; Ginsberg, A.M.; Becker, P.(2012). Phase II dose-ranging trial of the early
bactericidal activity of PA-824. Journal of Antimicrobial Agents and Chemotherapy. 56, 3027
3231.
Diacon AH, Donald PR, Pym A,(2012). Randomized pilot trial of eight weeks of bedaquiline
(TMC207) treatment for multidrug-resistant tuberculosis: longterm outcome, tolerability, and
effect on emergence of drug resistance. Journal of Antimicrobial Agents and Chemother. 56(8),
32713276.
Escribano, I.; Rodrguez, J.C.; Llorca, B.; Garca-Pachon, E.; Ruiz, M.; Royo, G.(2007) Importance of
the efflux pump systems in the resistance of Mycobacterium tuberculosis to fluoroquinolones
and linezolid. Chemotherapy 53, 397401.
Fbrega, A., Madurga, S., Giralt, E., Vila, J.(2009). Mechanism of action of and resistance to
quinolones. Microbial Biotechnology. 2, 4061.
Fischl,M.A.,Uttamchandani,R.B.,Daikos,G.L.,Poblete,R.B.,Moreno,J.N.,Reyes,R.R.,Boota,A.M.,Tho
mpson,L.M.,Clearly,T.J., and Lai,S.(1992). An outbreak of tuberculosis caused by
multiple-drug-resistant tubercle bacilli among patients with HIV infection.Annals of internal
Medicine,117(11),177-183.
Finken, M., Kirschner, P., Meier, A., Wrede, A., Bttger, E.C.(1993). Molecular basis of streptomycin
resistance in Mycobacterium tuberculosis: Alterations of the ribosomal protein S12 gene and
point mutations within a functional 16S ribosomal RNA pseudoknot. Molecular Microbiology.
9(7), 12391246.
Gandhi, N.R.; Moll, A.; Sturm, A.W.; Pawinski, R.; Govender, T.; Lalloo, U.; Zeller, K.; Andrews, J.;
Friedland, G.(2006). Extensively drug-resistant tuberculosis as a cause of death in patients co-
infected with tuberculosis and HIV in a rural area of South Africa. Lancet.368, 15751580
Goss, W.A.; Deitz, W.H.; Cook, T.M.(1965). Mechanism of action of nalidixic acid on Escherichia
coli. II. Inhibition of deoxyribonucleic acid synthesis. Journal of Bacteriology, 89(2), 1068
1074.
Grzegorzewicz, A.E.; Kordulkov, J.; Jones, V.; Born, S.E.; Belardinelli, J.M.; Vaqui, A.; Gundi,
V.A.; Madacki, J.; Slama, N.; Laval, F.(2012) A common mechanism of inhibition of the
Mycobacterium tuberculosis mycolic acid biosynthetic pathway by isoxyl and thiacetazone. J.
Biol. Chem. 287, 3843438441.
Huitric, E.; Verhasselt, P.; Andries, K.; Hoffner, S.E.(2007) In vitro antimycobacterial spectrum of a
diarylquinoline ATP synthase inhibitor. Journal of Antimicrobial Agents and Chemotherapy,
51(4), 42024204.
Makarov, V.; Manina, G.; Mikusova, K.; Mllmann, U.; Ryabova, O.; Saint-Joanis, B.; Dhar, N.;
Pasca, M.R.; Buroni, S.; Lucarelli, A.P.(2009) Benzothiazinones kill Mycobacterium
tuberculosis by blocking arabinan synthesis. Science 324, 801804.
Maruri, F.; Sterling, T.R.; Kaiga, A.W.; Blackman, A.; van der Heijden, Y.F.; Mayer, C.; Cambau, E.;
Aubry, A.(2012) A systematic review of gyrase mutations associated with fluoroquinolone-
resistant Mycobacterium tuberculosis and a proposed gyrase numbering system. Journal on
Antimicrobial Chemotherapy, 67(6), 819831.
Matsumoto, M.; Hashizume, H.; Tomishige, T.; Kawasaki, M.; Tsubouchi, H.; Sasaki, H.;
Shimokawa, Y.; Komatsu, M.(2006) OPC-67683, a nitro-dihydro-imidazooxazole derivative
with promising action against tuberculosis in vitro and in mice. PLoS Med. 3, e466.
Mikusov, K.; Huang, H.; Yagi, T.; Holsters, M.; Vereecke, D.; DHaeze, W.; Scherman, M.S.;
Brennan, P.J.; McNeil, M.R.; Crick, D.C.(2005). Decaprenylphosphoryl arabinofuranose, the
donor of the D-arabinofuranosyl residues of mycobacterial arabinan, is formed via a two-step
epimerization of decaprenylphosphoryl ribose. Journal of Bacteriology, 187, 80208025.
Palomino, J.C.; Martin, A.(2013). Tuberculosis clinical trial update and the current anti-tuberculosis
drug portfolio. Current Medical Chemothrapy. 20, 37853796.
Palomino, J.C.; Martin, A.(2013). TMC207 becomes bedaquiline, a new anti-TB drug. Future
Microbiology 8, 10711080.
Pasca, M.R.; Degiacomi, G.; Ribeiro, A.L.; Zara, F.; De Mori, P.; Heym, B.; Mirrione, M.; Brerra,
R.; Pagani, L.; Pucillo, L.(2010) Clinical isolates of Mycobacterium tuberculosis in four
European hospitals are uniformly susceptible to benzothiazinones. Antimicrob. Agents
Chemother. 54,16161618.
Protopopova, M.; Hanrahan, C.; Nikonenko, B.; Samala, R.; Chen, P.; Gearhart, J.; Einck, L.; Nacy,
C.A.(2005) Identification of a new antitubercular drug candidate, SQ109, from a combinatorial
library of 1,2-ethylenediamines. J. Antimicrob. Chemother. 56, 968974.
Rawat, R.; Whitty, A.; Tonge, P.J.(2003) The isoniazid-NAD adduct is a slow, tight-binding inhibitor
of InhA, the Mycobacterium tuberculosis enoyl reductase: Adduct affinity and drug resistance.
Proc. Natl. Acad. Sci. USA, 100, 1388113886
Reddy, V.M.; Einck, L.; Andries, K.; Nacy, C.A.(2010) In vitro interactions between new
antitubercular drug candidates SQ109 and TMC207. Antimicrob. Agents Chemother. 54, 2840
2846
Rinder, H.; Thomschke, A.; Rsch-Gerdes, S.; Bretzel, G.; Feldmann, K.; Rifai, M.; Lscher,
T.(1998) Significance of ahpC promoter mutations for the prediction of isoniazid resistance in
Mycobacterium tuberculosis. European Journal of Clinical Microbiology and Infectious
Diseases, 17, 508511.
Ramaswamy, S.; Musser, J.M.(1998) Molecular genetic basis of antimicrobial agent resistance in
Mycobacterium tuberculosis: update. Tuberculosis and Lung Disease,79(2), 329.
Ramaswamy, S.V.; Reich, R.; Dou, S.J.; Jasperse, L.; Pan, X.; Wanger, A.; Quitugua, T.; Graviss,
E.A.(2003). Single nucleotide polymorphisms in genes associated with isoniazid resistance in
Mycobacterium tuberculosis. Journal of Antimicrobial Agents Chemotherapy 47(8), 1241
1250.
Simons, S.O.; Mulder, A.; van Ingen, J.; Boeree, M.J.; van Soolingen, D.(2013) Role of rpsA gene
sequencing in diagnosis of pyrazinamide resistance. J. Clin. Microbiol. 51, 382.
Somoskovi, A.; Parsons, L.M.; Salfinger, M.(2001) The molecular basis of resistance to isoniazid,
rifampin, and pyrazinamide in Mycobacterium tuberculosis. Respir. Res. 2, 164168.
Sun, Z.; Zhang, J.; Zhang, X.; Wang, S.; Zhang, Y.; Li, C.(2008) Comparison of gyrA gene mutations
between laboratory-selected ofloxacin-resistant Mycobacterium tuberculosis strains and clinical
isolates. Int. J. Antimicrob. Agents 31, 115121.
Suzuki, Y.; Katsukawa, C.; Tamaru, A.; Abe, C.; Makino, M.; Mizuguchi, Y.; Taniguchi, H(1998).
Detection of kanamycin-resistant Mycobacterium tuberculosis by identifying mutations in the
16S rRNA gene. Journal of Clinical Microbiology, 36(2), 12201225.
Takayama, K.; Kilburn, J.O.(1989). Inhibition of synthesis of arabinogalactan by ethambutol in
Mycobacterium smegmatis. Journal of Antimicrobial Agents and Chemotherapy 33(2),1493
1499.
Takiff, H.E.; Salazar, L.; Guerrero, C.; Philipp, W.; Huang, W.M.; Kreiswirth, B.; Cole, S.T.; Jacobs,
W.R., Jr.; Telenti, A.(1994).Cloning and nucleotide sequence of Mycobacterium tuberculosis
gyrA and gyrB genes and detection of quinolone resistance mutations. Journal of Antimicrobial
Agents and Chemotherapy. 38, 773780.
Vilchze, C.; Av-Gay, Y.; Attarian, R.; Liu, Z.; Hazbn, M.H.; Colangeli, R.; Chen, B.; Liu, W.;
Alland, D.; Sacchettini, J.C.(2008). Mycothiol biosynthesis is essential for ethionamide
susceptibility in Mycobacterium tuberculosis. Molecular Microbiology, 69(9), 13161329.
Von Groll, A.; Martin, A.; Jureen, P.; Hoffner, S.; Vandamme, P.; Portaels, F.; Palomino, J.C.; da
Silva, P.A.(2009).Fluoroquinolone resistance in Mycobacterium tuberculosis and mutations in
gyrA and gyrB. Antimicrob. Agents Chemother. 53, 44984500.
World Health Organization,(2010). Multidrug and Extensively Drug-resistant TB (M/XDR-TB);
Global Report on Surveillance and Response. Retrieved from http://www.stoptb.org/wg/gli
(Retrieved 29 January,2016).
Zhang, Y.; Heym, B.; Allen, B.; Young, D.; Cole, S(1992). The catalase-peroxidase gene and
isoniazid resistance of Mycobacterium tuberculosis. Nature .358, 591593.
Zhang, Y.(2005). The magic bullets and tuberculosis drug targets. Annual Review of Pharmacology
and Toxicology, 45(6), 529564.