Intra Cavitary Pharmacokinetics and Drug Resistance in Pulmonary Tuberculosis

描述（申请人提供）：结核病是一个巨大的全球公共卫生问题，也是传染病导致死亡的第二大原因。全球出现的耐多药结核病是有效控制结核病的一个重大障碍。用于治疗耐多药结核病的二线抗结核药物的应答率远低于治疗药物敏感结核病的应答率。最近的报告强调了在SLD治疗期间发生额外耐药性的重大风险。在耐多药结核病治疗过程中耐药性扩大的机制方面存在着重大的知识差距。我们的初步数据表明，结核腔可能是进一步耐药发展的位点。在此背景下，我们假设耐多药结核病患者的肺空洞由于亚治疗的腔内SLD浓度而促进耐药性的发展和扩大。加强对SLD药代动力学的了解，包括组织渗透特性和耐药机制，将有助于指导改进耐多药结核病的治疗和预防战略。本提案的具体目标包括：1）确定关键SLD（左氧氟沙星和卷曲霉素）在接受MDR-TB治疗的患者血浆、肺组织和空洞肺中的药代动力学。利用在格鲁吉亚共和国接受预防性手术的耐多药结核病患者的独特患者队列和创新的微透析方法，我们将评估包括肺腔（M浓度最高的部位）在内的各个隔室中的SLD浓度。结核病（MTB）。2)研究从痰、肺和空洞肺组织中回收的结核分枝杆菌分离株的表型和基因型耐药谱。我们建议进行全基因组测序和生物信息学分析，比较来自同一患者不同部位（空洞、更多正常肺组织、痰液）的成对MTB分离株，以确定空洞是否是耐药性发展和扩增的部位，并研究空洞环境中MTB的群体动力学。3)确定SLD组织水平与来自切除空洞肺的MTB分离株中其他耐药突变的发生之间的关系。我们将使用AIMS 1和2沿着的药代动力学和基因组测序数据以及药代动力学建模，以评估低药物浓度是否与耐药性增加相关。拟议的研究将提供关于扩大耐药性机制的新数据，并将挑战我们目前给药SLD和治疗患有空洞性疾病的耐多药结核病患者的方式。我的长期目标是成为一名独立的临床和转化研究者和结核病（TB）的全球领导者，专注于耐药结核病的机制，传播和毒力。K23奖将对我的职业发展至关重要，并为研究和研究培训提供受保护的时间。制定了一项培训计划，将培训目标与研究提案的每个具体目标联系起来。在K23获奖期间，我将积累临床研究、药代动力学研究设计和建模、微透析、细菌基因组学（包括DNA测序）以及生物信息学分析方面的专业知识。我的职业发展计划将正式教学法、实验室培训和实践指导与解决全球结核病优先事项的相关研究经验相结合。由临床结核病研究、基因组学和药代动力学领域公认的领导者组成的多学科团队将在颁奖期间提供专业和科学的指导。K23奖将允许调查和积累额外的数据，随后可以作为后续R 01应用的基础，重点是涉及肺腔调查的转化研究。埃默里大学的大量智力和物质资源以及与国家结核病和肺部疾病中心（NCTBLD）的格鲁吉亚合作伙伴建立的合作关系为开展这项转化研究提供了独特的机会。格鲁吉亚NCTBLD也与埃默里大学有着长期的富有成效的合作历史，包括许多正在进行的资助研究项目（包括NIH Fogarty赠款的网站）。埃默里大学是一所研究型大学，每年有超过5亿美元的研究资金。传染病的埃默里分部有59名全职教师，包括临床结核病，药代动力学和细菌基因组学研究的领导者。埃默里罗林斯公共卫生学院，埃默里全球健康研究所和亚特兰大临床和转化科学研究所（ACTSI，NIH资助的CTSA）为职业提升，发展和研究培训提供了进一步的优秀资源。该提案还将受益于与佛罗里达大学的合作 传染病药代动力学实验室（IDPL）。IDPL是抗分枝杆菌药物浓度的国家参考实验室，在进行微透析方面拥有广泛的专业知识。

DESCRIPTION (provided by applicant): Tuberculosis is an enormous global public health problem and the second leading cause of death due to an infectious disease. The global emergence of multidrug-resistant (MDR) TB is a significant barrier to effective TB control. Response rates to second-line anti-TB drugs (SLDs) used to treat MDR-TB are much lower than those for treatment of drug susceptible TB. Recent reports highlight the substantial risk of development of additional drug resistance during SLD treatment. Critical knowledge gaps exist regarding the mechanisms of amplified drug resistance during treatment of MDR-TB. Our preliminary data suggests that the TB cavity may be the site of further drug resistant development. With this background, we have hypothesized that pulmonary cavities in patients with MDR-TB facilitate the development and amplification of drug resistance as a result of sub-therapeutic intra-cavitary SLD concentrations. An enhanced understanding of SLD pharmacokinetics including tissue penetration properties and mechanisms of drug resistance will help guide improved MDR-TB treatment and prevention strategies. The Specific AIMs of this proposal include: 1) To determine the pharmacokinetics of key SLDs (levofloxacin and capreomycin) in plasma, pulmonary tissue, and cavitary lung among patients undergoing treatment for MDR-TB. Utilizing a unique patient cohort of MDR-TB patients undergoing adjunctive surgery in the Republic of Georgia and an innovative microdialysis method we will assess SLD concentrations among various compartments including pulmonary cavities, the site of the highest concentration of M. tuberculosis (MTB). 2) To investigate phenotypic and genotypic drug resistance profiles of MTB isolates recovered from sputum, lung, and cavitary lung tissue. We propose to perform whole genome sequencing and bioinformatics analysis comparing paired MTB isolates from different sites in the same patients (cavity, more normal lung tissue, sputum) to determine if cavities are sites of drug resistance development and amplification and to study population dynamics of MTB within the cavitary environment. 3) To determine the relationship between SLD tissue levels and the development of additional drug resistance mutations in MTB isolates from resected cavitary lung. We will use the pharmacokinetic and genomic sequencing data derived from AIMS 1 and 2 along with pharmacokinetic modeling to assess if low drug concentrations are associated with increasing drug resistance. The proposed investigations will provide novel data on mechanisms of amplified drug resistance and will challenge the way we currently dose SLDs and treat MDR-TB patients with cavitary disease. Candidate My long-term goal is to become an independent clinical and translational investigator and global leader in tuberculosis (TB) focusing on the mechanisms, transmission, and virulence of drug-resistant TB. A K23 award would be critical to my career development and provide protected time for research and research training. A Training Plan has been developed that links a training goal to each of the specific aims of the research proposal. During this K23 award period, I will build expertise in clinical research, pharmacokinetics study design and modeling, performing microdialysis, bacterial genomics including DNA sequencing, and performing bioinformatics analysis. My career development plan combines formal didactics, laboratory training, and hands on mentoring with relevant research experiences that address global TB priorities. A multi-disciplinary team of recognized leaders in clinical TB research, genomics, and pharmacokinetics will provide professional and scientific mentorship during the award period. The K23 award will allow for the investigation and accumulation of additional data that can subsequently serve as the basis for a subsequent R01 application focused on translational research involving investigation of the pulmonary cavity. Environment The substantial intellectual and physical resources of Emory University and established collaborations with partners in the country of Georgia at the National Center for Tuberculosis and Lung Disease (NCTBLD) provide a unique opportunity to carry out this translational research. The Georgian NCTBLD also has a long history of productive collaborations with Emory University including numerous ongoing funded research projects (including the site of a NIH Fogarty grant). Emory University is a research-intensive university with over half a billion dollars in research funding each year. The Emory Division of Infectious Diseases has 59 full time faculty members including leaders in clinical TB, pharmacokinetics and bacterial genomics research. The Emory Rollins School of Public Health, Emory Global Health Institute, and the Atlanta Clinical and Translational Science Institute (ACTSI, the NIH-funded CTSA) provide further excellent resources for career enhancement, development and research training. The proposal will also benefit from collaboration with the University of Florida Infectious Diseases Pharmacokinetics Laboratory (IDPL). The IDPL is a national reference laboratory for anti-mycobacterial drug concentrations and has extensive expertise in performing microdialysis.