Detection of a historic reservoir of bedaquiline/clofazimine resistance-associated variants in Mycobacterium tuberculosis

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Camus Nimmo1,2, Arturo Torres Ortiz3,4, Cedric C.S. Tan4, Juanita Pang4, Mislav Acman4, James Millard5,6,7, Leonardo Montagnani8, Alison D. Grant5,9, Max O’Donnell8,10, Alex Pym5, Ola Brynildsrud11, Vegard Eldholm11, Louis Grandjean12,13, Xavier Didelot14, François Balloux15, Lucy van Dorp16
1Africa Health Research Institute, Durban, South Africa. [email protected].
2UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK. [email protected].
3Department of Medicine, Imperial College London, UK
4UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK.
5Africa Health Research Institute, Durban, South Africa
6Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
7Wellcome Trust Liverpool Glasgow Centre for Global Health Research, Liverpool, UK.
8CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
9TB Centre, London School of Hygiene & Tropical Medicine, London, UK
10Department of Medicine & Epidemiology, Columbia University Irving Medical Center, New York, NY, USA.
11Division of Infectious Diseases and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway.
12Division of Infection and Immunity, University College London, London, UK
13Laboratorio de Investigacion y Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru.
14School of Life Sciences and Department of Statistics, University of Warwick, Coventry, UK.
15UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK. [email protected].
16UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK. [email protected].

Tóm tắt

Abstract Background Drug resistance in tuberculosis (TB) poses a major ongoing challenge to public health. The recent inclusion of bedaquiline into TB drug regimens has improved treatment outcomes, but this advance is threatened by the emergence of strains of Mycobacterium tuberculosis (Mtb) resistant to bedaquiline. Clinical bedaquiline resistance is most frequently conferred by off-target resistance-associated variants (RAVs) in the mmpR5 gene (Rv0678), the regulator of an efflux pump, which can also confer cross-resistance to clofazimine, another TB drug. Methods We compiled a dataset of 3682 Mtb genomes, including 180 carrying variants in mmpR5, and its immediate background (i.e. mmpR5 promoter and adjacent mmpL5 gene), that have been associated to borderline (henceforth intermediate) or confirmed resistance to bedaquiline. We characterised the occurrence of all nonsynonymous mutations in mmpR5 in this dataset and estimated, using time-resolved phylogenetic methods, the age of their emergence. Results We identified eight cases where RAVs were present in the genomes of strains collected prior to the use of bedaquiline in TB treatment regimes. Phylogenetic reconstruction points to multiple emergence events and circulation of RAVs in mmpR5, some estimated to predate the introduction of bedaquiline. However, epistatic interactions can complicate bedaquiline drug-susceptibility prediction from genetic sequence data. Indeed, in one clade, Ile67fs (a RAV when considered in isolation) was estimated to have emerged prior to the antibiotic era, together with a resistance reverting mmpL5 mutation. Conclusions The presence of a pre-existing reservoir of Mtb strains carrying bedaquiline RAVs prior to its clinical use augments the need for rapid drug susceptibility testing and individualised regimen selection to safeguard the use of bedaquiline in TB care and control.

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Tài liệu tham khảo

World Health Organization. Global tuberculosis report 2022. (WHO, 2022).

Cegielski JP, et al. Multidrug-resistant Tuberculosis treatment outcomes in relation to treatment and initial versus acquired second-line drug resistance. Clin Infect Dis. 2016;62:418–30. https://doi.org/10.1093/cid/civ910.

World Health Organization. Global tuberculosis report 2019. (2019).

Andries K, et al. A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis. Science. 2005;307:223–7. https://doi.org/10.1126/science.1106753.

Diacon AH, et al. Multidrug-resistant tuberculosis and culture conversion with bedaquiline. N Engl J Med. 2014;371:723–32. https://doi.org/10.1056/NEJMoa1313865.

Food and Drug Administration. SIRTURO approval letter. Retrieved Jan 15, 2024, from https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2012/204384orig1s000ltr.pdf.

Borisov SE. et al. Effectiveness and safety of bedaquiline-containing regimens in the treatment of MDR- and XDR-TB: a multicentre study. Eur Respir J 2017;49. https://doi.org/10.1183/13993003.00387-2017

Guglielmetti L. et al. Long-term outcome and safety of prolonged bedaquiline treatment for multidrug-resistant tuberculosis. Eur Respir J 2017;49. https://doi.org/10.1183/13993003.01799-2016

Olayanju O. et al. Long-term bedaquiline-related treatment outcomes in patients with extensively drug-resistant tuberculosis from South Africa. Eur Respir J 2018;51. https://doi.org/10.1183/13993003.00544-2018

Ndjeka N. et al. High treatment success rate for multidrug-resistant and extensively drug-resistant tuberculosis using a bedaquiline-containing treatment regimen. Eur Respir J 2018;52. https://doi.org/10.1183/13993003.01528-2018

World Health Organization. Module 4: treatment - drug-resistant tuberculosis treatment, 2022 update. (2022).

Conradie F, et al. Bedaquiline-Pretomanid-Linezolid regimens for drug-resistant Tuberculosis. N Engl J Med. 2022;387:810–23. https://doi.org/10.1056/NEJMoa2119430.

Berry C, et al. TB-PRACTECAL: study protocol for a randomised, controlled, open-label, phase II-III trial to evaluate the safety and efficacy of regimens containing bedaquiline and pretomanid for the treatment of adult patients with pulmonary multidrug-resistant tuberculosis. Trials. 2022;23:484. https://doi.org/10.1186/s13063-022-06331-8.

Paton NI, Cousins C, Suresh C. Treatment strategy for rifampin-susceptible tuberculosis. Reply N Engl J Med. 2023;388:2298. https://doi.org/10.1056/NEJMc2304776.

Manson AL, et al. Genomic analysis of globally diverse Mycobacterium tuberculosis strains provides insights into the emergence and spread of multidrug resistance. Nat Genet. 2017;49:395–402. https://doi.org/10.1038/ng.3767.

Cohen KA, et al. Evolution of extensively drug-resistant Tuberculosis over four decades: Whole genome sequencing and dating analysis of Mycobacterium tuberculosis isolates from KwaZulu-Natal. PLoS Med. 2015;12:e1001880. https://doi.org/10.1371/journal.pmed.1001880.

Eldholm V, Balloux F. Antimicrobial resistance in Mycobacterium tuberculosis: the odd one out. Trends Microbiol. 2016;24:637–48. https://doi.org/10.1016/j.tim.2016.03.007.

Huitric E, et al. Rates and mechanisms of resistance development in Mycobacterium tuberculosis to a novel diarylquinoline ATP synthase inhibitor. Antimicrob Agents Chemother. 2010;54:1022–8. https://doi.org/10.1128/AAC.01611-09.

Almeida D, et al. Mutations in pepQ confer low-level resistance to Bedaquiline and Clofazimine in Mycobacterium tuberculosis. Antimicrob Agents Chemother. 2016;60:4590–9. https://doi.org/10.1128/AAC.00753-16.

Andries K, et al. Acquired resistance of Mycobacterium tuberculosis to bedaquiline. PLoS ONE. 2014;9:e102135. https://doi.org/10.1371/journal.pone.0102135.

Hartkoorn RC, Uplekar S, Cole ST. Cross-resistance between clofazimine and bedaquiline through upregulation of MmpL5 in Mycobacterium tuberculosis. Antimicrob Agents Chemother. 2014;58:2979–81. https://doi.org/10.1128/AAC.00037-14.

Poulton NC, Azadian ZA, DeJesus MA, Rock JM. Mutations in rv0678 confer low-level resistance to Benzothiazinone DprE1 inhibitors in Mycobacterium tuberculosis. Antimicrob Agents Chemother. 2022;66:e0090422. https://doi.org/10.1128/aac.00904-22.

Vargas R Jr, et al. Role of epistasis in Amikacin, Kanamycin, Bedaquiline, and Clofazimine resistance in Mycobacterium tuberculosis Complex. Antimicrob Agents Chemother. 2021;65:e0116421. https://doi.org/10.1128/AAC.01164-21.

Bloemberg GV, et al. Acquired resistance to Bedaquiline and Delamanid in therapy for Tuberculosis. N Engl J Med. 2015;373:1986–8. https://doi.org/10.1056/NEJMc1505196.

Xu J. et al. Primary Clofazimine and Bedaquiline resistance among isolates from patients with multidrug-resistant tuberculosis. Antimicrob Agents Chemother 2017;61. https://doi.org/10.1128/AAC.00239-17

Zimenkov DV, et al. Examination of bedaquiline- and linezolid-resistant Mycobacterium tuberculosis isolates from the Moscow region. J Antimicrob Chemother. 2017;72:1901–6. https://doi.org/10.1093/jac/dkx094.

de Vos M, et al. Bedaquiline microheteroresistance after cessation of Tuberculosis treatment. N Engl J Med. 2019;380:2178–80. https://doi.org/10.1056/NEJMc1815121.

Ghodousi A. et al. Acquisition of cross-resistance to Bedaquiline and Clofazimine following treatment for Tuberculosis in Pakistan. Antimicrob Agents Chemother 2019;63. https://doi.org/10.1128/AAC.00915-19

Polsfuss S, et al. Emergence of low-level delamanid and Bedaquiline resistance during extremely drug-resistant tuberculosis treatment. Clin Infect Dis. 2019;69:1229–31. https://doi.org/10.1093/cid/ciz074.

Mokrousov I, Akhmedova G, Polev D, Molchanov V, Vyazovaya A. Acquisition of bedaquiline resistance by extensively drug-resistant Mycobacterium tuberculosis strain of Central Asian outbreak clade. Clin Microbiol Infect. 2019;25:1295–7. https://doi.org/10.1016/j.cmi.2019.06.014.

Kadura S, et al. Systematic review of mutations associated with resistance to the new and repurposed Mycobacterium tuberculosis drugs bedaquiline, clofazimine, linezolid, delamanid and pretomanid. J Antimicrob Chemother. 2020;75:2031–43. https://doi.org/10.1093/jac/dkaa136.

Roberts LW. et al. Repeated evolution of bedaquiline resistance in Mycobacterium tuberculosis is driven by truncation of mmpR5. bioRxiv, 2022.2012.2008.519610. 2022. https://doi.org/10.1101/2022.12.08.519610

Sonnenkalb L, et al. Bedaquiline and clofazimine resistance in Mycobacterium tuberculosis: an in-vitro and in-silico data analysis. Lancet Microbe. 2023;4:e358–68. https://doi.org/10.1016/S2666-5247(23)00002-2.

Ismail N, et al. Genetic variants and their association with phenotypic resistance to bedaquiline in Mycobacterium tuberculosis: a systematic review and individual isolate data analysis. Lancet Microbe. 2021;2:E604–16. https://doi.org/10.1016/S2666-5247(21)00175-0.

World Health Organization. Catalogue of mutations in Mycobacterium tuberculosis complex and their association with drug resistance. 2023. https://iris.who.int/handle/10665/374061. Accessed 31 Jan 2024.

World Health Organization. Technical report on critical concentrations for TB drug susceptibility testing of medicines used in the treatment of drug-resistant TB. 2018.

Nimmo C. et al. Bedaquiline resistance in drug-resistant tuberculosis HIV co-infected patients. Eur Respir J 2020;55. https://doi.org/10.1183/13993003.02383-2019

Martinez E, et al. Mutations associated with in vitro resistance to Bedaquiline in Mycobacterium tuberculosis isolates in Australia. Tuberculosis (Edinb). 2018;111:31–4. https://doi.org/10.1016/j.tube.2018.04.007.

Timm J, et al. Baseline and acquired resistance to bedaquiline, linezolid and pretomanid, and impact on treatment outcomes in four tuberculosis clinical trials containing pretomanid. PLOS Glob Public Health. 2023;3:e0002283. https://doi.org/10.1371/journal.pgph.0002283.

Villellas C, et al. Unexpected high prevalence of resistance-associated Rv0678 variants in MDR-TB patients without documented prior use of clofazimine or bedaquiline. J Antimicrob Chemother. 2017;72:684–90. https://doi.org/10.1093/jac/dkw502.

Merker M, et al. Phylogenetically informative mutations in genes implicated in antibiotic resistance in Mycobacterium tuberculosis complex. Genome Med. 2020;12:27. https://doi.org/10.1186/s13073-020-00726-5.

Coll F, et al. A robust SNP barcode for typing Mycobacterium tuberculosis complex strains. Nat Commun. 2014;5:4812. https://doi.org/10.1038/ncomms5812.

Sobkowiak B, et al. Identifying mixed Mycobacterium tuberculosis infections from whole genome sequence data. BMC Genomics. 2018;19:613. https://doi.org/10.1186/s12864-018-4988-z.

Brynildsrud OB, et al. Global expansion of Mycobacterium tuberculosis lineage 4 shaped by colonial migration and local adaptation. Sci Adv. 2018;4:eaat5869.

Bradley P, den Bakker HC, Rocha EPC, McVean G, Iqbal Z. Ultrafast search of all deposited bacterial and viral genomic data. Nat Biotechnol. 2019;37:152–9. https://doi.org/10.1038/s41587-018-0010-1.

Merker M, et al. Evolutionary history and global spread of the Mycobacterium tuberculosis Beijing lineage. Nat Genet. 2015;47:242–9. https://doi.org/10.1038/ng.3195.

Luo T, et al. Southern East Asian origin and coexpansion of Mycobacterium tuberculosis Beijing family with Han Chinese. Proc Natl Acad Sci U S A. 2015;112:8136–41. https://doi.org/10.1073/pnas.1424063112.

Norheim G, et al. Tuberculosis outbreak in an educational institution in Norway. J Clin Microbiol. 2017;55:1327–33. https://doi.org/10.1128/JCM.01152-16.

Kay GL, et al. Eighteenth-century genomes show that mixed infections were common at time of peak tuberculosis in Europe. Nat Commun. 2015;6:6717. https://doi.org/10.1038/ncomms7717.

Nimmo C, et al. Population-level emergence of bedaquiline and clofazimine resistance-associated variants among patients with drug-resistant tuberculosis in southern Africa: a phenotypic and phylogenetic analysis. Lancet Microbe. 2020;1:e165–74. https://doi.org/10.1016/S2666-5247(20)30031-8.

Nimmo C, et al. Dynamics of within-host Mycobacterium tuberculosis diversity and heteroresistance during treatment. EBioMedicine. 2020;55:102747. https://doi.org/10.1016/j.ebiom.2020.102747.

Nimmo C, et al. Whole genome sequencing Mycobacterium tuberculosis directly from sputum identifies more genetic diversity than sequencing from culture. BMC Genomics. 2019;20:389. https://doi.org/10.1186/s12864-019-5782-2.

Dheda K, et al. Outcomes, infectiousness, and transmission dynamics of patients with extensively drug-resistant tuberculosis and home-discharged patients with programmatically incurable tuberculosis: a prospective cohort study. Lancet Respir Med. 2017;5:269–81. https://doi.org/10.1016/S2213-2600(16)30433-7.

Streicher EM, et al. Molecular epidemiological interpretation of the epidemic of extensively drug-resistant Tuberculosis in South Africa. J Clin Microbiol. 2015;53:3650–3. https://doi.org/10.1128/JCM.01414-15.

Guerra-Assuncao JA. et al. Large-scale whole genome sequencing of M. tuberculosis provides insights into transmission in a high prevalence area. Elife 2015;4. https://doi.org/10.7554/eLife.05166

Grandjean L, et al. Transmission of multidrug-resistant and drug-susceptible Tuberculosis within households: a prospective cohort study. PLoS Med. 2015;12:e1001843. https://doi.org/10.1371/journal.pmed.1001843. discussion e1001843.

Grandjean L, et al. Convergent evolution and topologically disruptive polymorphisms among multidrug-resistant tuberculosis in Peru. PLoS ONE. 2017;12:e0189838. https://doi.org/10.1371/journal.pone.0189838.

Ismail N, Omar SV, Ismail NA, Peters RPH. Collated data of mutation frequencies and associated genetic variants of bedaquiline, clofazimine and linezolid resistance in Mycobacterium tuberculosis. Data Brief. 2018;20:1975–83. https://doi.org/10.1016/j.dib.2018.09.057.

Ghajavand H. et al. High prevalence of Bedaquiline resistance in treatment-naive tuberculosis patients and Verapamil effectiveness. Antimicrob Agents Chemother 2019;63. https://doi.org/10.1128/AAC.02530-18

Fowler PW. 2017 pygsi v.1.0.0: a Python class to interrogate BIGISI. 2018. https://doi.org/10.5281/zenodo.1407085.

Li H. Aligning sequence reads, clone sequences and assembly contigs with BWA-MEM. arXiv 2013. arXiv:1303.3997

Van der Auwera GA, et al. From FastQ data to high confidence variant calls: the genome analysis toolkit best practices pipeline. Curr Protoc Bioinformatics. 2013;11(10):11–111033. https://doi.org/10.1002/0471250953.bi1110s43.

Okonechnikov K, Conesa A, Garcia-Alcalde F. Qualimap 2: advanced multi-sample quality control for high-throughput sequencing data. Bioinformatics. 2016;32:292–4. https://doi.org/10.1093/bioinformatics/btv566.

Hariguchi N. et al. OPC-167832, a novel carbostyril derivative with potent antituberculosis activity as a DprE1 Inhibitor. Antimicrob Agents Chemother 2020;64. https://doi.org/10.1128/AAC.02020-19

Phelan JE, et al. Integrating informatics tools and portable sequencing technology for rapid detection of resistance to anti-tuberculous drugs. Genome Med. 2019;11:41. https://doi.org/10.1186/s13073-019-0650-x.

Coll F, et al. Rapid determination of anti-tuberculosis drug resistance from whole-genome sequences. Genome Med. 2015;7:51. https://doi.org/10.1186/s13073-015-0164-0.

The Cryptic Consortium. A data compendium associating the genomes of 12,289 Mycobacterium tuberculosis isolates with quantitative resistance phenotypes to 13 antibiotics. PLoS Biol. 2022;20:e3001721. https://doi.org/10.1371/journal.pbio.3001721.

Page AJ, et al. SNP-sites: rapid efficient extraction of SNPs from multi-FASTA alignments. Microb Genom. 2016;2:e000056. https://doi.org/10.1099/mgen.0.000056.

Kozlov AM, Darriba D, Flouri T, Morel B, Stamatakis A. RAxML-NG: a fast, scalable and user-friendly tool for maximum likelihood phylogenetic inference. Bioinformatics. 2019;35:4453–5. https://doi.org/10.1093/bioinformatics/btz305.

Didelot X, Croucher NJ, Bentley SD, Harris SR, Wilson DJ. Bayesian inference of ancestral dates on bacterial phylogenetic trees. Nucleic Acids Res. 2018;46:e134. https://doi.org/10.1093/nar/gky783.

Menardo F, et al. Treemmer: a tool to reduce large phylogenetic datasets with minimal loss of diversity. BMC Bioinformatics. 2018;19:164. https://doi.org/10.1186/s12859-018-2164-8.

Bouckaert R, et al. BEAST 2.5: An advanced software platform for Bayesian evolutionary analysis. PLoS Comput Biol. 2019;15:e1006650. https://doi.org/10.1371/journal.pcbi.1006650.

Bouckaert RR, Drummond AJ. bModelTest: Bayesian phylogenetic site model averaging and model comparison. BMC Evol Biol. 2017;17:42. https://doi.org/10.1186/s12862-017-0890-6.

Baele G, et al. Improving the accuracy of demographic and molecular clock model comparison while accommodating phylogenetic uncertainty. Mol Biol Evol. 2012;29:2157–67. https://doi.org/10.1093/molbev/mss084.

Paradis E, Schliep K. ape 5.0: an environment for modern phylogenetics and evolutionary analyses in R. Bioinformatics. 2019;35:526–8. https://doi.org/10.1093/bioinformatics/bty633.

Yu GC, Smith DK, Zhu HC, Guan Y, Lam TTY. GGTREE: an R package for visualization and annotation of phylogenetic trees with their covariates and other associated data. Methods Ecol Evol. 2017;8:28–36. https://doi.org/10.1111/2041-210x.12628.

O’Neill MB, et al. Lineage specific histories of Mycobacterium tuberculosis dispersal in Africa and Eurasia. Mol Ecol. 2019;28:3241–56. https://doi.org/10.1111/mec.15120.

Rutaihwa LK, et al. Multiple Introductions of Mycobacterium tuberculosis lineage 2-Beijing into Africa over centuries. Front Ecol Evol. 2019;7:ARTN 112. https://doi.org/10.3389/fevo.2019.00112.

Bradley P, et al. Rapid antibiotic-resistance predictions from genome sequence data for Staphylococcus aureus and Mycobacterium tuberculosis. Nat Commun. 2015;6:10063. https://doi.org/10.1038/ncomms10063.

Menardo F, Duchene S, Brites D, Gagneux S. The molecular clock of Mycobacterium tuberculosis. PLoS Pathog. 2019;15:e1008067. https://doi.org/10.1371/journal.ppat.1008067.

Ismail N, Peters RPH, Ismail NA, Omar SV. Clofazimine exposure in vitro selects efflux pump mutants and Bedaquiline resistance. Antimicrob Agents Chemother 2019;63. https://doi.org/10.1128/AAC.02141-18

Andres S, et al. Bedaquiline-resistant tuberculosis: dark clouds on the horizon. Am J Respir Crit Care Med. 2020;201:1564–8. https://doi.org/10.1164/rccm.201909-1819LE.

The Cryptic Consortium. Epidemiological cutoff values for a 96-well broth microdilution plate for high-throughput research antibiotic susceptibility testing of M. tuberculosis. Eur Respir J 2022;2200239. https://doi.org/10.1183/13993003.00239-2022

Rancoita PMV. et al. Validating a 14-drug microtiter plate containing Bedaquiline and Delamanid for large-scale research susceptibility testing of Mycobacterium tuberculosis. Antimicrob Agents Chemother 2018;62. https://doi.org/10.1128/AAC.00344-18

Beckert P, et al. MDR M. tuberculosis outbreak clone in Eswatini missed by Xpert has elevated bedaquiline resistance dated to the pre-treatment era. Genome Med. 2020;12:104. https://doi.org/10.1186/s13073-020-00793-8.

Loiseau C, et al. An African origin for Mycobacterium bovis. Evol Med Public Health. 2020;2020:49–59. https://doi.org/10.1093/emph/eoaa005.

Bateson A, et al. Ancient and recent differences in the intrinsic susceptibility of Mycobacterium tuberculosis complex to pretomanid. J Antimicrob Chemother. 2022;77:1685–93. https://doi.org/10.1093/jac/dkac070.

D’Costa VM, et al. Antibiotic resistance is ancient. Nature. 2011;477:457–61. https://doi.org/10.1038/nature10388.

Rifat D, et al. Mutations in fbiD (Rv2983) as a novel determinant of resistance to pretomanid and delamanid in Mycobacterium tuberculosis. Antimicrob Agents Ch. 2021;65:ARTN e01948–20. https://doi.org/10.1128/AAC.01948-20.

Koser CU, Maurer FP. Minimum inhibitory concentrations and sequencing data have to be analysed in more detail to set provisional epidemiological cut-off values for Mycobacterium tuberculosis complex. Eur Respir J 2023;61. https://doi.org/10.1183/13993003.02397-2022

Kahlmeter G, Turnidge J. The determination of epidemiological cut-off values requires a systematic and joint approach based on quality controlled, non-truncated minimum inhibitory concentration series. Eur Respir J 2023;61. https://doi.org/10.1183/13993003.02259-2022

World Health Organization. Optimized broth microdilution plate methodology for drug susceptibility testing of Mycobacterium tuberculosis complex. 2022. https://iris.who.int/handle/10665/353066.

Liu Y, et al. Reduced susceptibility of Mycobacterium tuberculosis to Bedaquiline during antituberculosis treatment and its correlation with clinical outcomes in China. Clin Infect Dis. 2021;73:e3391–7. https://doi.org/10.1093/cid/ciaa1002.

Pym AS, et al. Bedaquiline in the treatment of multidrug- and extensively drug-resistant tuberculosis. Eur Respir J. 2016;47:564–74. https://doi.org/10.1183/13993003.00724-2015.

Grandjean L, et al. The association between Mycobacterium Tuberculosis genotype and drug resistance in Peru. PLoS ONE. 2015;10: e0126271. https://doi.org/10.1371/journal.pone.0126271.

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