New diagnostics and drugs for TB

Bernard Fourie PhD
Medicine in Need (MEND)

Changing Trends in TB Diagnostics
Symptoms X-ray Molecular Probes Culture Liquid Smear DST Culture Solid

Developed Countries

Growing Shift Developing Countries
Courtesy: S Sidiqui (Becton-Dickson)

Bacteriology Realization that culture is the only definitive diagnosis Culture is necessary for ID and AST Going to remain as a “Gold Standard” for a long time Rapid Turnaround Time is critical More focus on liquid media Courtesy: S Sidiqui (Becton-Dickson) .

CDC Guidelines AFB Smear Results within 24 hours -------Culture Results report ave. 2 Weeks -------.Yes* *Role of BACTEC in meeting the guidelines Courtesy: S Sidiqui (Becton-Dickson) . Media and Reagents -----------.Yes* QC.Yes* Complete culture/Identification 3 Weeks -----Yes* Complete Culture/ID/DST in 4 weeks -------. Method.

FIND’s Diagnostic Pipeline .

FIND Product Deliverables 2006-2013 n tio ciast e Sp te re ltu cu DST uid & Liq TB M ate om AT t Au NA d Reference Lab ed as est or e b ce t Flu opy ag an c D Ph ist LEcros res Mi C PO AT A N ary rin AT U A N 10-40% % Access after 5 years Peripheral Lab AG ry naction i Urete d ed as r bw e ad lo Re T F LA B /A AG d ve t pro tes Im rip st 70% Clinic Health post 95% 2006 2007 2008 2009 2010 2011 2012 2013 .

Disa Lima Norte . INNO Lipa test.FIND/TDR Trial in Peru* Comparison of FASTPlaque-Response test. Inst Nat Salud. and direct LJ DST Gold standard: indirect DST on LJ medium Costing sub-study Enrolled newly diagnosed and retreatment patients with SS+ PTB Additional 400 SS+ for FP sub-study Discrepant analysis for all RIF-R tests by repeat DST and rpoΒ sequencing *IMT Cayetano Heredia.

FASTPlaque™-Response FASTPlaqueResponse assay procedure Sputum collection Specimen processing (NALC-NaOH) o/n incubation ± rifampicin Interpretation of results .

FIND/TDR Trial in Peru Preliminary Results Performance Characteristics for RIF-R* Test Sens Spec PPV INNO 93% 99% 93% FP-1 95% 96% 79% FP-2 ** 94% 100% 100% D-LJ 95% 99% 95% *Subject to change pending results of discrepant analysis **Based on results 135 tests with complete results NPV 99% 99% 99% 99% .

FIND/TDR Trial in Peru Preliminary Results Performance Characteristics for MDR TB* Test Sens Spec PPV INNO 94% 97% 84% FP-1 94% 95% 70% D-LJ 97% 98% 85% *Subject to change pending results of discrepant analysis NPV 99% 99% 100% .

.Species Identification Rapid identification needed for culturebased systems. DNA probes. PCR. HPLC expensive FIND working with TAUNS/BD to evaluate performance of Capilia TB test in MGIT case finding demonstration projects . especially broth culture Current technologies.g. e.

IJTLD 2005. et al. tb complex but not MOTT or some BCG strains Consists of nitrocellulose membrane with anti-MPB64 mouse antibodies conjugated with colloidal gold With antigen-antibody reaction.9:1409-11 . 100% specificity* 3 false negatives with MPB64 gene mutation *D.tb complex): 92% sensitivity.Capilia TB Assay Immunochromatic assay based on detection of MPB64. see red-purple band within 15 minutes Evaluated for 172 mycobacterial isolates (119 M. present in M. Hilleman.

Molecular Methods Good performance characteristics Rapid Sensitive (approaching culture) Specific Expensive and requires sophisticated technology FIND working with partners with core technology and platform suitable for developing country use .

LAMP • Closed system • Isothermal • Rapid • Multiprimer • Visible readout .

procedure • time-to-result < 2 h • throughput: > 16 tests / day / module • no need for biosafety cabinet • integrated controls • true random access GeneXpert System module Performance • specific for MTB • sensitivity better than smear.MTB / Rif-resistance test Workflow • sputum • simple 1-step external sample prep. similar to culture • detection of rif-resistance via rpoB gene MTB Product and system design • test cartridges for GeneXpert System • several GeneXpert modules can be combined in 1 workstation • swap replacement of detection unit • ~1 day technician training for non-mycobacteriologists cartridge .

adult TB contacts .000 HIV+/.FIND Evaluation Studies of Interferongamma release assay (IGRA) IGRAs have been shown to be as sensitive and more specific than the TST for diagnosis of latent TB infection (LTBI) Limited data suggest that IGRAs perform well in HIV-infected persons FIND supporting two studies nested in CREATE projects to help define role of IRGAs in diagnosing LTBI in HIV+ persons: THRio: 3000 patients in HIV/AIDS care clinics ZAMSTAR: 10.

Exposed to ESAT-6 and CFP-10 antigens. Interferon-g producing cells counted Whole blood exposed to ESAT-6 and CFP-10 TB antigens Interferon-g Production Quantified .Interferon-γ based tests Whole Blood Assay QuantiFERON-TB Gold Cellestis T Cell Test T Spot TB Assay Oxford Immunotech WBC’s separated.

centrifuge. pipetter) Refrigerated reagents High cost Useful in low prevalence settings and high-burden HIV .The Interferon-γ Assays Pro’s Differentiates TB infection from BCG Suitable for repeat. or reader. incubator. No “booster phenomenon” Objective results. in vitro procedure Results available in 24 hours No patient’s second visit Specificity (~99%) Sensitivity (90s%) Con’s Does not differentiate between latent TB and active disease Multiple assays steps Blood drawing. transport. test within 12-hours Technique dependent Equipment requirements (Spec.

NIAID TBRU. NIAID TBRU. Johns Hopkins University. TB Alliance Moxifloxacin Bayer Pharmaceuticals. Tuberculosis Research Centre. NIAID. TB Alliance Novel Antibiotic Class GlaxoSmithKline. Sankyo Nitroimidazo-oxazole Back-up Otsuka Clinical Testing Diarylquinoline TMC207 Johnson & Johnson Gatifloxacin OFLOTUB Consortium. NIAID InhA Inhibitors GlaxoSmithKline. Wellesley College Cell Wall Inhibitors Colorado State University. TAACF. University of Auckland Preclinical Diamine SQ-109 Sequella Inc. TAACF. WHO TDR Nitrofuranylamides NIAID. NIH STOP TB New Drugs Working Group . Novartis Institute for Tropical Diseases. TB Alliance Quinolones KRICT/ Yonsei University..Global TB Drug Portfolio: Sep 2005 Discovery Carboxylates TB Alliance. TB Alliance Nitroimidazole PA-824 Chiron Corporation. Dipiperidines (SQ-609) Sequella Inc. TB Alliance Isocitrate Lyase Inhibitors (ICL) GlaxoSmithKline. CDC TBTC. TB Alliance Macrolides TB Alliance. TB Alliance Picolinamide Imidazoles NIAID. TB Alliance Nitroimidazo-oxazole OPC-67683 Otsuka Pyrrole LL-3858 Lupin Limited Screening and Target Identification AstraZeneca Thiolactomycin Analogs NIAID. California State University. Translocase I Inhibitors Sequella Inc. University of Illinois at Chicago Methyltransferase Inhibitors Anacor Pharmaceuticals Natural Products Exploration BIOTEC. University of Tennessee Nitroimidazole Analogs NIAID. Non-Fluorinated Quinolone TaiGen Synthase Inhibitor FAS20013 FASgen Inc. ITR. NIAID. Lupin. NIAID Dihydrolipoamide Acyltransferase Inhibitors Cornell University. TAACF) Pleuromutilins GlaxoSmithKline.

Ltd. Tropical Disease Research for Disease Control and Prevention .. IRD*. TB Alliance. WHO TDRο. University College of London. CDC♦. Lupin Ltd. Bayer. Johns Hopkins University Johnson & Johnson (Tibotec) Otsuka Pharmaceutical Co. TB Alliance Lupin Ltd.Clinical Development Pipeline Compound gatifloxacin Development Stage Phase III Sponsor / Coordinator EC / OFLOTUB Consortium. moxifloxacin TMC 207 OPC-67683 PA-824 LL-3858 ο World Phase II / III Early Bactericidal Activity Early Bactericidal Activity Phase I Phase I * Institut de Recherche pour le Developement ♦ Centers Health Organization.

Pipeline Compounds 2005 Moxifloxacin Gatifloxacin J&J Otsuka Lupin PA-824 Sequella II II I/II I I I I 2006 2007 III III 2008 2009 2010 NDA NDA 2011 2012 2013 I/II I/II I I III II/III II/III II/III II/III NDA NDA NDA NDA NDA Identify and develop best combination regimen(s) .

Short-/Medium-term prospects More potent fluoroquinolones Moxifloxacin Gatifloxcin Levofloxacin Capreomycin PAS Injectable (Inhaled dry-powder formulation in advanced development) Tablets Granular with acid-resistant outer coating Capsules (Liposomal) (Other members of class high potency against MDR) Clofazimine .

0 2. Hooper Clin. 30 : 243254 . Dis. AAC 2000 .Ratio Cmax on MIC90 of the main fluoroquinolones Drug (mg) Ciprofloxacin 500 Ofloxacin 400 Levofloxacin 500 Sparfloxacin 200 Moxifloxacin 400 Cmax (µg/ml) 1-2 4 5-7 1. 44 : 2600-2603 23 . 28 : 716-721 . Lubasch et al.1 4-5 MIC90 Cmax/MIC90 1.0 1.0 0. Inf.. : Hooper et Wolfson AAC 1985 .5 0.5 1-2 2 5-7 2 8-10 Ref. 2000 .

R = rifampin.Activity of Moxi in Combination Therapy 10 9 [Grosset et al] Log CFU in entire lung 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 Untreated 2RHZ+4RH 2RHZM+4RHM 2RMZ+4RM Duration of treatment (mos.) M = moxifloxacin. H = isoniazid. Z = pyrazinamide .

Antimicrob Agents Chemother.Moxifloxacin in treatment of MDRTB* Activity of the OFX-containing third-line regimen against M. whereas when OFX was replaced by MXF. 9 months of treatment with a modified third-line regimen (MXF/AMK/ETH/PZA) displayed bactericidal activity comparable to that of 6 months of treatment with the standard regimen in mice *Veziris N et al. tuberculosis was rather weak in vivo. 2003 Oct.47(10):3117-22 .

0136 0.0 0 10 20 30 D a y s o n th e r a p y 40 50 60 *Preliminary data presented at IUATLD Conference. Paris 2005 Oflotub Consortium Study supported by EC and WHO/TDR .6 0.Gatifloxacin.4 0.8 1.69 p= 0.0 Log rank test H H H H R R R R Z Z Z Z E O G M 0. moxifloxacin or ofloxacin replacing ethambutol in conventional HRZE regimen – Conversion of sputum during 1st two months* Probability of sputum conversion 0.2 χ2 (3)=10.

NEJM 1995) .Survival of HIV-associated MDRTB – NYC Treatment (Turret.

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