Characterisation of the pncA gene in Mycobacterium tuberculosis isolates from Gauteng, South Africa.

SETTING: The use of pyrazinamide (PZA) is important for the treatment of Mycobacterium tuberculosis as it is bactericidal to semi-dormant mycobacteria that are not affected by other drugs. The incidence of resistance to PZA and other drugs used in the treatment of M. tuberculosis is increasing in South Africa. OBJECTIVE: To characterise the pncA gene of M. tuberculosis isolates from Gauteng, South Africa, and to develop a rapid diagnostic method. DESIGN: The pncA gene and the putative regulatory gene were characterised by sequence analysis in a total of six PZA susceptible and 15 resistant isolates. The association with classical PZA susceptibility testing and PZase activity was determined. RESULTS: All PZA-resistant isolates were PZase negative as well as resistant to at least one other anti-tuberculosis drugs. Mutations were identified throughout the length of the pncA gene in 10/15 PZA-resistant isolates. Five lacked PZase activity, but the wild type pncA sequence was present. In all six PZase-positive strains, a PZA-susceptible pattern was obtained on BACTEC and the wild type pncA sequence was present. CONCLUSION: Sequencing is an effective means to identify mutations in the pncA gene in M. tuberculosis and therefore resistance to PZA. The fact that some PZA-resistant M. tuberculosis isolates lack mutations in the pncA gene suggests that alternative mechanisms for drug resistance exist. In PZase negative strains with no genetic changes which are resistant to 100 microg/ml and susceptible to 300 microg/ml, 300 microg/ml may be a more reliable breakpoint.     

The paradox of pyrazinamide: an update on the molecular mechanisms of pyrazinamide resistance in Mycobacteria

Pyrazinamide (PZA) is an important front line anti-tuberculosis drug because of its sterilizing activity against semi-dormant tubercle bacilli. In spite of its remarkable role in shortening the treatment duration from 9 months to 6 months when used in combination with Rifampicin and Isoniazid, PZA remains a difficult paradox because of its incompletely understood mode of action and mechanism of resistance. PZA is a nicotinamide analog prodrug which is converted into the active bactericidal form pyrazinoic acid by the bacterial enzyme pyrazinamidase (PZase). PZA does not appear to have a specific cellular target and instead, exerts its bactericidal effect by disrupting the membrane energetics and acidification of cytoplasm. Majority (72-97%) of PZA-resistant isolates of M. tuberculosis exhibit mutations in their pncA gene or upstream area leading to loss of PZase activity. A wide diversity of pncA mutations scattered along the entire length of pncA gene is unique to PZA resistance. However, PZA resistant isolates with normal PZase activity and wild type pncA sequences have also been reported in several studies which indicate that alternate mechanisms of PZA resistance exist. Investigations into these mechanisms would be useful in developing alternative diagnostic/therapeutic measures. This review presents the update of various mechanisms of PZA resistance in different mycobacteria with special emphasis on mode of action of PZA and mechanisms of resistance in Mycobacterium tuberculosis.     

结核分枝杆菌耐利福平药物机理的初步研究

目的通过诱导试验观察结核菌产生耐利福平药物的全过程,初步分析结核菌耐该药的机理。方法采用诱导试验、聚合酶链反应—单链构象多态性(PCR-SSCP)和序列分析,对经不同药物浓度传代培养后的结核菌强毒株（H₃₇Rv）和36株临床耐药分离株进行分析。结果在诱导到第7代时,H₃₇Rv的PCR-SSCP电泳出现异常,经测序证实在513位点发生基因突变。36株临床耐药分离株中有23株发生突变,为63.9% (23/36);其中有5株与诱导株基因突变位点相同。结论用药物不间断的刺激结核菌,是产生结核菌耐利福平药物的重要原因。     

结核分支杆菌耐吡嗪酰胺分离株pncA基因突变的研究

目的 了解我国结核分支杆菌耐吡嗪酰胺（ＰＺＡ）分离株ｐｎｃＡ基因突变情况,研究其与耐ＰＺＡ之间的关系。方法 通过聚合酶链反应（ＰＣＲ）－单链构象多态性（ＳＳＣＰ）和ＰＣＲ－循环测序法（ＡＳ）分析７４株结核分支杆菌临床分离株的ｐｎｃＡ基因。以结核分支杆菌Ｈ３７ＲＶ标准株为对照。结果３２株药物敏感株ｐｎｃＡ基因ＳＳＣＰ分析未发现异常。２０株耐非ＰＺＡ药物的分离株中,１６株ｐｎｃＡ基因ＳＳＣＰ泳动正常;     

Frequency and implications of pyrazinamide resistance in managing previously treated tuberculosis patients.

OBJECTIVE: To determine the extent of pyrazinamide (PZA) resistance in isolates from previously treated patients from the Western Cape, South Africa. DESIGN: Drug-resistant isolates, isolates resistant to one or more drugs other than PZA (PZA resistance is not routinely determined) (n = 127), and drug-susceptible (n = 47) clinical isolates of Mycobacterium tuberculosis from previously treated patients from the Western Cape were phenotypically (BACTEC MGIT 960) and genotypically (pncA gene sequencing) analysed for PZA resistance. RESULTS: MGIT analysis found that 68 of the 127 drug-resistant isolates were PZA-resistant. Nearly all (63/68) PZA-resistant isolates had diverse nucleotide changes scattered throughout the pncA gene, and five PZA-resistant isolates had no pncA mutations. Of the 47 phenotypically susceptible isolates, 46 were susceptible to PZA, while one isolate was PZA-monoresistant (OR = 53.0, 95% CI = 7.1-396.5). A pncA polymorphism (Thr114Met) that did not confer PZA resistance was also identified. PZA resistance was strongly associated with multidrug-resistant tuberculosis (MDR-TB). CONCLUSION: An alarmingly high proportion of South African drug-resistant M. tuberculosis isolates are PZA-resistant, indicating that PZA should not be relied upon in managing patients with MDR-TB in the Western Cape. A method for the rapid detection of PZA resistance would be beneficial in managing patients with suspected drug resistance.     

Discrepant results between pyrazinamide susceptibility testing by the reference BACTEC 460TB method and pncA DNA sequencing in patients infected with multidrug-resistant W-Beijing Mycobacterium tuberculosis strains

BACKGROUND: Mycobacterium tuberculosis strains belonging to the W-Beijing family have received broad clinical and public health attention because of their rapid worldwide spread and their frequent association with outbreaks, multidrug resistance, and treatment failures and relapses. METHODS: The present study examined a large number of multidrug-resistant strain-W isolates (isolates of 29 patients) by susceptibility testing for pyrazinamide (PZA) using the reference BACTEC 460TB method (Becton Dickinson Diagnostic Instrument Systems; Sparks, MD) and also by DNA sequencing of the pncA gene. RESULTS: We found that despite of the presence of a strain W-specific Thr47Ala in the pncA gene, all strains showed susceptibility to PZA in the reference BACTEC 460TB system due to their higher minimum inhibitory concentrations (relative to BACTEC 460TB PZA-susceptible strains). CONCLUSIONS: Our results suggest that the current radiometric reference method cannot reproducibly detect PZA resistance in patients infected with W-Beijing strains. Therefore, PZA susceptibility testing should instead be based on analysis of the pncA gene for resistance-associated mutations.     

结核分支杆菌五种耐药基因检测的临床应用及评价

目的　检测结核分支杆菌rpoBkatG、rpsL、pncA和embB耐药基因 ,评价其临床应用价值。方法　采用聚合酶链反应 单链构象多态性 (PCR SSCP)分析和药敏试验 (比例法 ) ,了解 10 9例肺结核患者结核分支杆菌耐药情况 ,并分析、比较临床治疗效果。结果　 1/ 2以上的肺结核患者至少耐两种抗结核药物 ,对RFP、INH、SM、PZA和EB总耐药率分别为 80 7%、71 5 %、78 8%、5 7 7%和48 6%。rpoB、katG、rpsL、pncA和embB基因突变率分别为 76%、68%、71%、5 1%和 3 0 %。结核分支杆菌耐药基因突变率与耐药水平联系密切 ,多数结核分支杆菌耐药基因突变易发生在高耐药株 ,也有少数基因突变发生在低耐药株。根据药敏试验和耐药基因检测结果 ,6个月耐多药结核治愈率分别达到 5 4 8%和 62 8% ,治疗效果满意 ,两种方法差异无显著性 (P >0 0 5 )。结论　耐药基因检测指导治疗是一种新探索 ,PCR SSCP方法敏感、特异 ,可以快速检测结核分支杆菌rpoB、katG、rpsL、pncA和embB耐药基因突变 ,可能会成为临床指导用药的好方法     

应用基因阵列法快速检测结核分枝杆菌rpoB基因突变

目的　研制一种新型的基因阵列 ,用于结核分枝杆菌耐利福平分离株rpoB基因突变的快速检测。方法　根据结核分枝杆菌rpoB基因序列设计寡核苷酸探针并制作基因阵列 ,用生物素标记的引物扩增结核分枝杆菌rpoB基因突变热点的目的片断 ,与基因阵列杂交 ,同时以聚合酶链反应 单链构象多态性 (PCR SSCP)技术及DNA测序法为对照。结果　 111株结核分枝杆菌临床分离株经PCR SSCP分析 ,4 1株RFP敏感株SSCP图谱与结核分枝杆菌标准株相同 ;70株耐RFP菌株中 ,6 3株(90 % )SSCP图谱与结核分枝杆菌标准株不同 ,其余 7株SSCP图谱与结核分枝杆菌标准株相同。基因阵列检测结果 4 1株RFP敏感株杂交图谱与标准株完全相同 ,70株耐RFP临床分离株中 ,6 3株检测到rpoB基因突变 ,检出率为 90 % ;其中 37株 (5 3% ) 5 31位丝氨酸 (Ser)置换 ,15株 (2 1% ) 5 2 6位组氨酸(His)置换 ,11株 (16 % )其他位置的氨基酸置换。基因阵列检测结果与PCR SSCP及测序结果一致。结论　用基因阵列法可简便、快速、准确地检测出大多数结核分枝杆菌耐利福平分离株的rpoB基因突变。     

The curious characteristics of pyrazinamide: a review.

Pyrazinamide (PZA) is an important sterilising tuberculosis drug that helps to shorten the duration of current chemotherapy regimens for tuberculosis. When first discovered, it had activity in murine tuberculosis but no apparent in vitro activity, and its subsequent use in treatment depended largely on classic experiments at Cornell University, which showed its requirement for an acid pH for activity and its sterilising activity in the mouse. Recent studies have shown that PZA enters Mycobacterium tuberculosis by passive diffusion, is converted to pyrazinoic acid (POA) by nicotinamidase/pyrazinamidase (PZase) and is then excreted by a weak efflux pump. Protonated POA (HPOA) is reabsorbed into the bacilli under acid conditions and accumulates because the efflux pump is inefficient, causing cellular damage. Unlike other antibacterials, PZA has no defined target of action. PZA is more active against old than against actively growing cultures, probably because the energy production and efflux pump would be slowed down by low bacterial metabolism. This review deals with the activity of PZA in vitro, in macrophages and in animal models. It describes the evidence from clinical trials that it is an effective sterilising drug that acts synergistically with rifampicin. The highly diverse mutations in the PZase gene (pncA) that lead to loss of PZase activity cause PZA resistance. Methods for susceptibility determination either as tests against PZA or nicotinamide in liquid and solid media, as tests for PZase activity or for mutations in pncA, are reviewed.     

Genotypic characterization of drug-resistant Mycobacterium tuberculosis isolates from Peru.

SETTING: Twenty-nine epidemiological unrelated and mostly multidrug-resistant Mycobacterium tuberculosis (MDR-TB) strains from Peruvian patients. OBJECTIVE: To investigate the molecular genetics of MDR-TB strains recovered in a Latin American country. DESIGN: Antimicrobial agent susceptibility testing, major genetic group designation, IS6110 fingerprinting, spoligotyping, and automated deoxyribonucleic acid sequencing of regions of the katG, rpoB, embB, gyrA, and pncA genes with mutations commonly associated with drug resistance. RESULTS: Nineteen isolates were found to be multidrug-resistant by susceptibility testing. IS6110 typing showed that virtually all isolates were unique and therefore had independently acquired drug resistance. Seventy-nine percent of isoniazid-resistant strains had a Ser315Thr amino acid change in KatG. Ninety-five percent of rifampin-resistant isolates had amino acid replacements in the rifampin-resistance determining region of RpoB. Six of 11 ethambutol-resistant strains had EmbB alterations. Eleven pyrazinamide-resistant strains had distinct mutations in pncA. CONCLUSION: Virtually all organisms evolved drug resistance independently. The types of drug resistance-associated mutations identified were very similar to changes occurring in isolates from other areas of the world. Nucleotide sequence-based strategies for rapid detection of drug resistance-conferring mutants will be applicable to organisms recovered in Peru, and potentially other areas of Latin America.     

Characterization of pyrazinamide and ofloxacin resistance among drug resistant Mycobacterium tuberculosis isolates from Singapore.

OBJECTIVES: To evaluate rapid molecular approaches for the detection of pyrazinamide (PZA) and ofloxacin resistance, by screening 100 known drug-resistant Mycobacterium tuberculosis isolates. METHODS: Mycobacterium tuberculosis isolates were tested for phenotypic resistance to pyrazinamide and ofloxacin using the BACTEC 460 radiometric method and the E-test, respectively. Mutation screening was done by amplifying the pncA, gyrA, and gyrB genes by the polymerase chain reaction (PCR) and direct automated sequencing. RESULTS: Twelve isolates were PZA-resistant and 8 of 12 (66.7%) isolates had missense mutations or deletions at the pncA gene, suggesting that mutation or deletion at the pncA gene is the major molecular mechanism of PZA resistance among the Singaporean isolates. Using the E-test, 48 isolates were resistant to ofloxacin, with minimum inhibitory concentrations of 4 microg/mL or higher. No mutations were observed at the quinolone resistance-determining region (QRDR) of gyrA in all isolates. At the QRDR of gyrB, mutations were present in 1 of 48 ofloxacin-resistant isolates and 0 of 19 ofloxacin-susceptible isolates. CONCLUSIONS: In Singapore, genotypic analysis of resistance to PZA and ofloxacin is inadequate and should be complemented by conventional methods.     

福建省46株耐多药结核分枝杆菌rpoB基因突变特征分析

[目的] 阐明来源于福建省耐药性调查的46株耐多药结核分枝杆菌rpoB基因的突变特征,为福建省耐多药结核病快速诊断方法的建立提供一定的分子基础。[方法] 对福建省9个监测点进行耐药性调查,收集菌株进行菌种鉴定、药物敏感性试验。选取46株耐多药结核分枝杆菌和15株全敏感株,扩增包含rpoB热点突变区的基因片段,测序后比对分析。[结果] 15株全敏感株未检测到突变。42株耐多药结核分枝杆菌rpoB基因检测到13种突变类型,涉及10个氨基酸,突变率为91.30%。突变均位于核心突变区内,包括9种点突变、 1个插入突变和3种联合突变,531位和526位密码子的点突变率之和达69.57%。[结论] 福建省耐多药结核分枝杆菌杆rpoB基因最常见的点突变位点为531位和526位。     

宁波地区耐多药结核分枝杆菌喹诺酮耐药gyr基因突变研究

目的 为阐明宁波地区耐多药结核分枝杆菌(Multiple drug-resistant tuberculosis, MDR-TB)的gyr基因突变特征,深入研究MDR-TB对喹诺酮类药物耐药与gyr基因突变特征的关系。方法 采用1%比例法对MDR-TB进行氧氟沙星药敏检测实验,通过 DNA直接测序法分析MDR-TB的gyr基因突变情况。结果 120株MDR-TB临床分离株中有34株对喹诺酮耐药,总耐药率为28.33%(34/120)。34株耐喹诺酮菌株中,30株gyr基因发生突变,突变率为88.24%(30/34)。30株gyr基因发生突变的菌株中gyrA基因突变有29株,占96.67%(29/30),突变位点包括90、91和94位氨基酸;gyrB基因突变有2株,其中1株均合并gyrA基因突变,占6.67%(2/30),突变位点包括499和502位氨基酸。结论 宁波地区MDR-TB对喹诺酮类药物耐药形势较为严峻,gyrA基因突变与MDR-TB对喹诺酮类药物耐药相关。     

Pyrazinamide and pyrazinoic acid activity against tubercle bacilli in cultured human macrophages and in the BACTEC system

Pyrazinamide (PZA) has become an essential component of current 6-month regimens for therapy of tuberculosis. Susceptible strains of tubercle bacilli convert PZA to pyrazinoic acid (POA) through pyrazinamidase (PZase), which resistant strains and Mycobacterium bovis bacille Calmette-Guérin lack. PZA susceptibility results obtained in cultured human macrophages were compared with those in the broth BACTEC system with 7H12 medium at pH 6.0 for strains known to be PZase-positive or -negative. Although added POA was unable to inhibit tubercle bacilli in cultured macrophages, it was able to inhibit them at very high concentrations in the BACTEC broth. Intracellularly formed POA would not be able to escape from the macrophage, and therefore would accumulate sufficiently to lower pH to toxic levels for tubercle bacilli. The results suggest that the cultured macrophages contribute actively or passively to the effectiveness of PZA, such as through the proposed mechanism of low pH generated by PZase in the phagolysosomes.     

结核分支杆菌inhA基因突变的测序研究

目的 对耐药结核分支杆的inhA基因进行测序分析以研究其变异的分子机制。方法 以inhA片段为引物,聚合酶链反应扩增H27Rv、耐药株和敏感株的inhA基因,产物克隆后制备质粒,ABI377全自动核酸测序系统测定DNA序列。结果 在17个耐异烟肼菌株中,11株出现inhA基因变异,突变率为65％,其中在10株至少每株有1个错义突变。变异主要为点突变,包括碱基置换和缺失。各菌株变异不同。katG和inhA同时变异的达62％。首次发现了18个与结核分支杆菌耐INH和EMB特性有关的inhA基因位点。结论 结核分支杆菌耐INH和EMB特性与inhA突变异致药物结合位点减少有关。     

适用于结核分枝杆菌微测序耐药基因芯片的多重PCR体系的优化与评价

目的优化结核分枝杆菌耐药相关基因多重PCR反应体系并评估其优缺点。方法利用改进的方法提取结核分枝杆菌基因组DNA,优化适合扩增rpoB,katG,mabA/inhA,pncA,embB,gyrA,rpsL,rrs和eis耐药基因片段的多重PCR体系,经测序确定所扩增出的基因片段,计算PCR操作过程所用的时间和材料成本等,分析多重PCR反应体系存在的优缺点。结果经过优化煺火温度、引物浓度以及添加NH 4^+和二甲基亚砜可以较好的扩增出5重和4重PCR产物,达到两管同时扩增9个结核分枝杆菌耐药相关基因的目的。利用该条件可以扩增出全部培养出的135株菌株DNA样本和80.56%的痰菌DNA样本,并且可以缩短PCR操作时间、降低试剂耗材成本,减少操作失误。结论优化的两管多重PCR法在同时扩增9个结核分枝杆菌耐药相关基因,具有明显的优势,具有良好的实用价值。     

Identification of mutations in the rpoB encoding the RNA polymerase beta subunit in rifampicine-resistant Mycobacterium tuberculosis strains from Iran

The aim of this study was to investigate the frequency, location and type of rpoB mutations in Mycobacterium tuberculosis isolated from patients in Iran. 91 sputum were collected from suspected tuberculosis patients, 34 Rif-r isolates (87%) were identified as M. tuberculosis. Polymerase chain reaction (PCR) amplification and DNA sequencing methods were performed. 411 bp fragments of rpoB gene were sequenced and mutations in 81 bp regions were analyzed. 60 mutations and 13 micro deletions were identified in 29 RIF-r MBT (85%). Among 60 mutations, 6 silent and 54 missense were identified. Missense mutations produced 23 types of amino acid substitutions. In 5 RIF-r MBT isolates (15%) no mutations were found in the core region of the rpoB gene. All silent mutations were localized in codon 507. Most frequent mutations detected from Iranian strains were in codons 523 and 526. Five alleles in codon 526 and 3 alleles in triplets in each codons 507, 508, 513 were found. 6 (19%) strains harboured single mutations 6 (18%) placed in codons 526, 510 while the rest of isolates 23 (69%) had multiple mutations: Double 11 (34%), triple 7 (22%), and quartile mutations 1 (3%) and 4 (12%) of strains harboured 5 mutations respectively.     

Identification of mycobacteria by sequencing of rpoB gene and 16S rRNA

PURPOSE: To classify a specific Mycobacterium among various mycobacteria utilizing sequencing of rpoB gene. To classify mycobacteria not identified by DNA-DNA hybridization (DDH) using sequencing of rpoB and 16S rRNA gene. OBJECTS AND METHODS: Classification of 106 Mycobacteria strains, one Nocardia strain, one Rhodococcus strain, four Gordona strains was made by using partial sequencing of rpoB and 16S rRNA (RIDOM). Thereafter, 38 mycobacteria clinical strains not identified by DDH were classified utilizing the DNA sequencing data. RESULTS: Pairs of M. kansasii and M. gastri, M. abscessus and M. chelonae, M.fortuitum (ATCC49404) and M. polcinum, M. peregrinum and M. septicum, M. farucinogense and M. senegalense and M. fortuitum (ATCC49403), Rhodococcus, Nocardia and Gordona strains were classified using sequencing of rpoB gene. Even though sequencing of rpoB and 16S rRNA gene was utilized, it was impossible to classify M. tuberculosis complex, M. avium family, M. marinum and M. ulcerans, and M. fortitum subsp. fortuitum and M. fortuitum subsp. acetamidolyticus. The 38 mycobacteria clinical strains not identified by DDH were successfully classified using sequencing of both rpoB and 16S rRNA. These sequencing analyses showed that M. heckeshornense, M. branderi, M. intermedium, M. shimoidei, M. wolinskyi, M. malmoense and M. lentiflavum could be identified. Thirty six clinical isolates (94.7%) and 32 clinical isolates (84.2%) were identified by rpoB sequencing and 16S rRNA sequencing (RIDOM), respectively. CONCLUSION: The classification ratio of mycobacteria including Nocardia, Rhodococcus and Gordona is 69.6% for sequencing of 16S rRNA and 89.3% for sequencing of rpoB gene. Sequencing of rpoB is useful for classification of mycobacteria due to its genetic diversity, but has some limitation in its application. In order to classify mycobacteria more accurately, it is important to combine sequencing of rpoB and 16S rRNA and biochemical/biological tests.     

应用基因芯片技术检测结核分枝杆菌链霉素耐药性的研究

目的研制一种新型DNA芯片,用于快速检测结核分枝杆菌耐链霉素rpsl和rrs基因突变。方法根据结核分枝杆菌rpsl和rrs基因序列设计探针并制作DNA芯片,用TAMRA(四甲基罗丹明)标记的引物扩增结核分枝杆菌rpsl和rrs基因突变热点的片段,与DNA芯片杂交,同时以聚合酶链反应-单链构象多态性(polymerase chain reaction-single stranded conformation polymorphism,PCR-SSCP)和DNA测序法为对照。结果144株结核分枝杆菌临床分离株中,42株链霉素敏感株的PCR-SSCP和DNA芯片杂交结果与结核分枝杆菌标准株完全相同;102株链霉素耐药株中有79株检测到rpsl基因突变77.5%(79/102),其中74株为43位密码子AAG→AGG突变,5株为88位密码子AAG→AGG突变;rrs基因突变5%(5/102),4株为513位密码子A→C突变,1株为516位密码子C→T突变,均与PCR-SSCP和DNA芯片杂交结果一致,余18株未检测到突变。结论用DNA芯片可快速、特异地检测出大多数结核分枝杆菌耐链霉素分离株的rpsl和rrs基因突变,可用于临床耐药性的检测,指导临床用药。