MYCOBACTERIUMTUBERCULOSIS AND ANTIBIOTIC RESISTANCE, A RE-

EMERGING DISEASE AND PUBLIC HEALTH PROBLEM

BY

OMORODION OGHOGHO HAPPY

AST/2382280145

A SEMINAR PAPER PRESENTED TO THE DEPARTMENT BIOLOGICAL SCIENCE

LABORATORY TECHNOLOGY, SCHOOL OF APPLIED SCIENCE AND
TECHNOLOGY, AUCHI POLYTECHNIC AUCHI

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF

HIGHER NATIONAL DIPLOMA (HND) IN (BIOLOGY/MICROBIOLOGY OPTION)

FEBRUARY, 2024

i
OUTLINE
 Abstract
 Introduction
 Epidemiology of tuberculosis
 Pathogenesis of tuberculosis
 Implications of transmission and acquired cases
 First-Line Anti-TB Drugs
 Second-Line Anti-TB Drugs
 New Anti-TB Drugs
 Conclusion
 References

ii
 ABSTRACT

Tuberculosis (TB) is a serious public health problem worldwide. Its situation is worsened by the
presence of multidrug resistant (MDR) strains of Mycobacterium tuberculosis, the causative
agent of the disease. In recent years, even more serious forms of drug resistance have been
reported. A better knowledge of the mechanisms of drug resistance of M. tuberculosisand the
relevant molecular mechanisms involved will improve the available techniques for rapid drug
resistance detection and will help to explore new targets for drug activity and development. This
review article discusses the mechanisms of action of anti-tuberculosis drugs and the molecular
basis of drug resistance in M. tuberculosis.

Keywords: Antibiotics, Drug Resistance, Molecular Mechanisms, Mycobacterium

Tuberculosis.

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 INTRODUCTION

Tuberculosis (TB) is an infectious disease caused by a group of closely related acid fast

aerobic, non-motile bacilli that belong to the Mycobacterium tuberculosis complex (M.TBC).

M.TBC bacteria are currently grouped into nine human-adapted phylogenetic lineages (L1–L9)

and four animal-associated lineages (Shuaib et al., 2022). Of these, the L2, L3, and L4 strains are

the most common worldwide. M.TBC is a group of genetically similar bacteria that cause

tuberculosis in a variety of hosts and comprises Mycobacterium tuberculosis,

Mycobacteriumafricanum, Mycobacterium bovis, Mycobacterium canettii, Mycobacterium

microti, Mycobacterium pinnipedii, and Mycobacterium caprae. This group also includes two

other species, Mycobacterium orygis and Mycobacterium mungi, that were previously designated

as separate species and have been identified as the causative pathogens for TB among banded

mongooses and East African oryx (CDC, 2016). Although all these microorganisms are

genetically similar, their phenotypes, host tropisms, and pathogenicity vary. M. tuberculosis is

responsible for more than 90% of human tuberculosis cases and it also is able to infect animals

that come into contact with infected people. Of the members of the M.TBC family, M. bovis has

the broadest spectrum of host infection, affecting humans as well as a wide range of domestic

and wild animals (Coscolla et al., 2021).

Tuberculosis (TB) remains as an important infectious disease and public health concern

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 reported

among HIV-infected persons (Kwan and Ernst 2016). However, even more disturbing is the

emergence of drug resistance. In 2012, there were an estimated 450,000 cases of multidrug

resistant (MDR)-TB and 170,000 deaths were due to it. MDR-TB is caused by strains of

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Mycobacterium tuberculosis that are resistant to at least rifampicin and isoniazid, two key drugs

in the treatment of the disease. Since 2006, it has been recognized the presence of even more

resistant strains of M. tuberculosis labelled as extensively drug resistant (XDR)-TB. These

strains in addition to being MDR are also resistant to any fluoroquinolone and to at least one of

the injectable second-line drugs: kanamycin, capreomycin or amikacin. More recently, a more

worrying situation has emerged with the description of M. tuberculosis strains that have been

found resistant to all antibiotics that were available for testing, a situation labelled as totally drug

resistant (TDR)-TB. Early detection of all forms of drug resistance in TB is a key factor to

reduce and contain the spread of these resistant strains. A better knowledge of the mechanisms of

action of anti-TB drugs and the development of drug resistance will allow identifying new drug

targets and better ways to detect drug resistance. The following sections will review the mode of

action and resistance mechanisms of the main anti-TB drugs as well as new drugs recently

described with anti-TB activity (Shuaib et al., 2022).

Antibiotics have played a crucial role in the reduction in the incidence of TB globally as

evidenced by the fact that before the mid-20th century, the mortality rate within five years of the

onset of the disease was 50%. The use of antibiotics has eliminated TB as a devastating disease,

but the challenge of resistance to anti-TB drugs, which had already been described at the time of

the introduction of streptomycin, has become a major global issue in disease management.

Mismanagement of multidrug-resistant tuberculosis (MDR-TB) cases, resulting from intermittent

drug use, prescription errors, and non-compliance of patients, has been identified as a critical risk

factor for the development of extensively drug-resistant tuberculosis (XDR-TB). Antimicrobial

resistance (AMR) in TB is a multi-factorial, complex problem of microbes evolving to escape

antibiotics, the gradual decline in antibiotic development, and different economic and social

conditions (Coscolla et al., 2021).

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Epidemiology of Tuberculosis

It is estimated that more than 90% of new TB cases and death occur in the high TB

burden developing countries. Multidrug anti-tuberculous therapy had been found effective when

using the Directly Observed Therapy Short Course (DOTS) strategy to improve compliance to

treatment of TB. With the emergence of MDR TB, the DOTS strategy was expanded to

accommodate second-line drugs in the Directly Observed Therapy short course with MDR

diagnosis, management, and treatment (DOTS PLUS) strategy. Treatment failure, however, can

still occur leading to relapse and development of drug-resistant TB strains to second-line drugs

which is the XDR TB (Ndjeka, 2014).

According to the WHO, Eastern Europe’s rates of MDR TB are the highest and MDR TB

makes up to 20% of all new TB cases, while in The Union State, it accounts for 28% of new TB

cases. In Africa, reports of MDR TB based on continuous surveillance as in South Africashow

progressively increasing MDR rates despite overall decreasing numbers of TB cases. This is

attributed to improved notification through laboratory surveillance. In developing countries with

limited access to TB drug sensitivity tests, prevalence of MDR TB is dependent on special

national surveysand hospital-based clinical researches as in Nigeria (WHO 2012).

Most of the hospital-based reports in Nigeria indicate that there is some level of MDR

TB, which though not documented on a regular basis show progressive increase over time. This

case scenario plays out in other developing countries where continuous surveillance or

monitoring of MDR TB is not available. In Nigeria, as well as in other high-burden countries

such as South Africa and India, it has been noted that the increasing TB prevalence may be

driven by HIV coinfection. Most of these reports are, however, based on testing of adult

populations (Adegboyega et al., 2014).

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Pathogenesis of Tuberculosis

Tuberculosis is an infectious bacterial disease caused by Mycobacterium tuberculosis

(M.tb), which is airborne and most commonly affects the lungs (known as pulmonary TB), but

can also spread to other parts of the body (known as extrapulmonary TB). As M.tb is essentially

only found in humans (there is no animal reservoir for it), it has evolved to persist in humans for

long time and only a fraction of people infected will develop active tuberculosis (about one

quarter of the world’s population is latently infected with M.tb according to the WHO 2022

report). After initial infection, about 90% of infected people do not develop active disease, and

M.tb can persist in the body for years (even a lifetime) without causing disease. People with

latent TB infection have no symptoms, are not contagious, and cannot spread TB to others.

However, without treatment, the dormant mycobacteria can wake up and develop TB disease

(active TB) in about 5% to 10% of infected people at some point in their lives (Patterson and

Wood , 2019). Whether infection results in bacterial eradication, containment, asymptomatic

infection, or active disease depends on the initial interaction between bacilli and AMs (Patterson

and Wood , 2019). Thus, not all people exposed to an infectious TB patient will become infected

with M. tuberculosis. The likelihood of TB transmission depends on several factors, the most

important of which are:

(1) the inhaled dose of infectious particles, which in turn depends on the bacillary load

in the sputum of the patient with active TB;

(2) the environment in which the exposure occurred (e.g., unventilated rooms increase

the risk of droplet transmission);

(3) the proximity of the individual to an infectious TB patient;

(4) the duration of exposure (people in close contact with TB patients increase the risk of

droplet transmission).

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If the macrophages fail to kill the bacilli, infected AMs migrate from the alveolar space into the

lung interstitium, where the bacilli infect other cells such as DCs and different macrophage

populations. The spread of bacilli from the site of infection is based on their ability to convert

these antimicrobial cells into a permissive cellular niche. At this stage, the bacteria can spread to

any part of the body (e.g., lymph nodes, lungs, spine, bones, or kidneys) via the lymphatic and

hematogenous pathways (Chandra et al., 2022)

Figure 1. Schematic representation of tuberculosis pathogenesis.

Source: Coscolla, et al., 2021

Implications of transmission and acquired cases

In the high-burden countries, there are reportedly 20-35.2% of new cases and 54-62% of

relapse cases that develop MDR TB, accounting for 82% of all incidences of MDR TB. Thus,

high burdens of MDRTB and XDR TB are eventually perpetuated from direct transmission

5
within communities. In cases where TB–HIV coinfections are also prevalent, this significantly

favors direct transmissibility. Direct transmission is therefore the most common way drug-

resistant TB is spread and this must be stemmed to arrest the imminent global health threat from

TB (Kwan and Ernst, 2011).

First-Line Anti-TB Drugs

 Rifampicin

Rifampicin is a rifamycin derivative introduced in 1972 as an antituberculosis agent. It is

one of the most effective anti-TB antibiotics and together with isoniazid constitutes the basis of

the multidrug treatment regimen for TB. Rifampicin is active against growing and non-growing

(slow metabolizing) bacilli (Alexander et al., 2012) The mode of action of rifampicin in M.

tuberculosis is by binding to the β-subunit of the RNA polymerase, inhibiting the elongation of

messenger RNA. (Migliori et al., 2012).

 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

active against metabolically-active replicating bacilli (Ndjeka 2014). Also known as isonicotinic

acid hydrazide, isoniazid is a pro-drug that requires activation by the catalase/peroxidase enzyme

KatG, encoded by the katG gene, to exert its effect. Isoniazid acts by inhibiting the synthesis of

mycolic acids through the NADH-dependent enoyl-acyl carrier protein (ACP)-reductase,

encoded by inhA (Migliori et al., 2012).

 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

interfering with the biosynthesis of arabinogalactan in the cell wall. In M. tuberculosis, the

6
genes embCAB, organized as an operon, code for arabinosyl transferase, which is involved in the

synthesis of arabinogalactan, producing the accumulation of the intermediate d-arabinofuranosyl-

P-decaprenol. (Migliori et al., 2012).

 Streptomycin

Originally isolated from the soil microorganism Streptomyces griseus, streptomycin was

the first antibiotic to be successfully used against TB. Unfortunately, as soon as it was

prescribed, resistance to it emerged, a result of being administered as monotherapy. Streptomycin

is an aminocyclitol glycoside active against actively growing bacilli and its mode of action is by

inhibiting the initiation of the translation in the protein synthesis. More specifically, streptomycin

acts at the level of the 30S subunit of the ribosome at the ribosomal protein S12 and the 16S

rRNA coded by the genes rpsL and rrs, respectively (Alexander et al., 2012).

Second-Line Anti-TB Drugs

 Fluoroquinolones

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,

discovered as a by-product of the antimalarial chloroquine. Newer-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 treatment in TB (Alexander et al., 2012).

The mode of action of fluoroquinolones is by inhibiting the topoisomerase II (DNA gyrase) and

topoisomerase IV, two critical enzymes for bacterial viability. These proteins are encoded by the

genes gyrA, gyrB, parC and parE, respectively. In M. tuberculosis, only type II topoisomerase

(DNA gyrase) is present and, thus, is the only target of fluoroquinolone activity (Shuaib et al.,

2022).

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  Kanamycin, Capreomycin, Amikacin, Viomycin

These four antibiotics have the same mechanism of action by inhibiting the protein

synthesis but, while kanamycin and amikacin are aminoglycosides, capreomycin and viomycin

are cyclic peptide antibiotics. All four are second-line drugs used in the management of MDR-

TB (Alexander et al., 2012).

 Ethionamide

Ethionamide is a derivative of isonicotinic acid structurally similar to isoniazid. It is also

a pro-drug requiring activation by a monooxygenase encoded by the ethA gene. It interferes with

the mycolic acid synthesis by forming an adduct with NAD that inhibits the enoyl-ACP

reductase enzyme. EthA is regulated by the transcriptional repressor EthR. Resistance to

ethionamide occurs by mutations in etaA/ethA, ethR and also mutations in inhA, which cause

resistance to both isoniazid and ethionamide. Moreover, studies with spontaneous isoniazid- and

ethionamide-resistant mutants of M. tuberculosis found that they map to mshA, encoding an

enzyme essential for mycothiol biosynthesis (Migliori et al., 2012).

 Para-Amino Salicylic Acid

Although it was one of the first anti-tuberculosis drugs used in the treatment of the

disease, together with isoniazid and streptomycin, para-amino salicylic acid or PAS is now

considered as a second-line drug part of the treatment regimen for MDR-TB. Until recently, its

mechanism of action was not completely defined. It has been proposed that being an analog of

para-amino benzoic acid, it must compete with it for dihydropteroate synthase, interfering in the

process of folate synthesis. A study using transposon mutagenesis identified mutations in the

thyA gene associated with resistance to PAS that were also present in clinical isolates resistant to

PAS(Migliori et al., 2012).

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  Cycloserine

Cycloserine is an oral bacteriostatic second-line anti-tuberculosis drug used in MDR-TB

treatment regimens. It is an analog of d-alanine that by blocking the activity of d-alanine: d-

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. Although the actual target of

cycloserine in M. tuberculosis is not completely elucidated, in previous studies in M. smegmatis

it was shown that overexpression of alrA led to resistance to cylcoserine in recombinant mutants.

More recently, it has also been shown that a point mutation in cycA, which encodes a d-alanine

transporter, was partially responsible for resistance to cycloserine in M. bovis BCG (Anthony et

al., 2016).

New Anti-TB Drugs

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

purpose of reducing the length of TB treatment (Reddy et al., 2010).

 Bedaquiline

Formerly known as TMC207 or R207910, bedaquiline is a new antibiotic belonging to

the class of diarylquinolines with specific activity against M. tuberculosis, which has also shown

in vitro activity against other non-tuberculous mycobacteria. Bedaquiline was discovered after a

high-throughput evaluation of thousands of compounds using Mycobacteriums megmatis in a

whole-cell assay. The drug showed in vitro and in vivo activity against M. tuberculosis and then

entered into clinical evaluation for drug susceptible and MDR-TB (Reddy et al., 2010

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  Delamanid

Delamanid, previously known as OPC-67683, is a derivative of nitro-dihydro-

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 (Reddy et al.,

2010).Delamanid was previously shown to have a very good in vitro and in vivo activity against

drug-susceptible and drug-resistant M. tuberculosis, as well as good early bactericidal activity

comparable to that of rifampicin, Delamanid has more recently shown its safety and efficacy in a

clinical evaluation for MDR-TB (Reddy et al., 2012).

 PA-824

PA-824 is a bicyclic derivative of nitroimidazole that showed specific activity against M.

tuberculosis. This small-molecule compound showed a very good in vitro and in vivo activity in

animal models and it also showed to be safe and well tolerated (Reddy et al., 2012).

 SQ-109

Compound SQ-109 is a synthetic analogue of ethambutol that has shown in vitro and in

vivo activity against drug-susceptible and drug-resistant M. tuberculosis. It has also been shown

to possess synergistic in vitro activity when combined with first-line drugs, and more

interestingly, when combined with bedaquiline and the oxazolidinone PNU-10048. SQ-109 is

currently being evaluated in a phase II clinical trial (Tahlan et al.,2012).

The mode of action of SQ-109 is by interfering with the assembly of mycolic acids into

the bacterial cell wall core, resulting in accumulation of trehalose monomycolate, a precursor of

the trehalose dimycolate (Tahlan et al.,2012).

 Benzothiazinones

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 A new class of drug with antimycobacterial activity, 1,3-benzothiazin-4-one or

benzothiazinone (BTZ), was recently described. The lead compound, 2-[2-S-methyl-1,4-dioxa-8-

azaspiro dec-8-yl-8-nitro-6-(trifluoromethyl)-4H-1,3-benzothiazin-4-one (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. Tuberculosis (Reddy et al., 2012).

Clinical and laboratory monitoring

Drugs used in the treatment of MDR TB are less effective, more toxic (90% experience

side effects), used for longer duration (usually more than 2 years’ duration), and are more costly

than drugs used in susceptible TB (10-100 times more costly). In the 27 high-burden countries,

the expenditure for MDR-TB treatment has increased cost of TB care from an estimated 1.3

billion USD in 2010 to 4.4 billion USD by 2015. Some of the common adverse effects might

also require monitoring such as ototoxicity and renal failure. There is also the need to document

improvement by follow-up of bacteriologic cultures. In addition to these, cases need to be

monitored because some MDR TB cases are in advanced stages of disease with other end-stage

organ failures. MDR TB therapy is often characterized by low treatment completion rates due to

death (15%), default (14-23%), and treatment failure (8-9%) (Pasca et al., 2010). To achieve

increased access, compliance, effective therapy, and retention in care, there is a need for close

monitoring. This is traditionally done by hospital-based care at MDR TB referral centers for the

initial therapy through health care providers. The model of care involves an initial hospitalization

until sputum culture conversion followed by ambulatory phase of treatment in the nearest DOTS

facility. However, hospital-based care may serve as an obstacle to access. Ambulatory-based care

and community-based care have been proposed in management of MDR TB cases. There have

been some successful experiences in some countries using these methods. There would be need

for collaboration between these models of care especially when dealing with patients with

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advanced disease who may benefit for some periods from hospital-based care but would need

community- or home-based care for terminal stages. Community and Ambulatory care also serve

to ensure adequate contact tracing for cases of MDR and XDR TB, which is of great importance

given the role of transmission of disease in spreading the MDR TB epidemic (Pasca et al., 2010).

When contacts are traced, there is need for DST to identify appropriate second-line drugs.

Currently, the diagnostic tools recommended are molecular-based testings: Line probe Assays

and Xpert MTB/RIF. There is need, however, to establish quality control measures for these tests

to avoid false positives and false negatives. Such tools as would ensure international standards

for reference laboratories and other peripheral centers have been developed in some countries.

Laboratory monitoring also includes structured assessment tools for TB microscopy, which is

shared among laboratory networks (Pasca et al., 2010).

Prevention of MDR TB

To achieve success in the control of MDR TB, there would be a need to strengthen

existing TB DOTS programs. To achieve this, some areas that should be focused on are the

creation of infection control policies both within and outside institutions. Health education of

how transmission of disease occurs from cases to vulnerable groups should be emphasized in

communities. Community-based care should be strengthened with recruitment of staff for contact

tracing of MDR cases, screening of the contacts, treatment administration, and identification of

those who are defaulting on treatment or require institutionalized care. There should be

expansion in the teams with involvement of all relevant health care partners to strengthen

Public–Private Mix initiatives for TB care and control (Pasca et al., 2010).

Infection control

This aims to prevent transmission from cases to other patients or health care workers. The

following means could help to ensure the protection of health care staff: Use of mask by all staff

12
on medical and TB isolation wards and in the HIV clinics. HIV testing of all staff with

reallocation of those testing positive to lower-risk positions; Annual Chest Xray screening for TB

for all staff. Within health care institutions, TB control officers should be hired as well as cough

officer in waiting areas who would identify those that are in hospital for other reasons but who

may require TB screening. The duration of hospital admission and stay should be reduced. There

should be environmental airflow control to ensure maximal ventilation (natural mechanical

ventilation within the ward and the use of outdoor waiting areas for outpatients). MDR TB

isolation wards should be created with attention paid to laminar airflow.

Infection control programs should be created with plans for intervention should transmission be

proved (Pasca et al., 2010).

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CONCLUSION

Drug resistance in TB remains a man-made phenomenon. It emerges as a result of

spontaneous gene mutations in M. tuberculosis that render the bacteria resistant to the most

commonly used anti-TB drugs. Among the reasons for this, the non-compliance with the

treatment regimens is signalled as the first cause. The standard treatment of TB calls for a six-

month regimen of four drugs that in the case of MDR-TB is extended to 18–24 months involving

second-line drugs. This makes compliance with the treatment regimens very challenging and the

rates of non-adherence could be high, resulting in poor outcomes and further dissemination of

MDR strains.

Notwithstanding the fact that mutations in a number of genes are clearly associated with

drug resistance in M. tuberculosis, there are still many cases where resistant strains do not

harbour any known mutation. For example, a recent study using whole-genome sequencing

identified new genes and internecine regions that were associated with drug resistance and its

evolution, showing that TB drug resistance is a phenomenon more complex than previously

assumed. More clarification is needed on the role of specific gene mutations and the

development of MDR- or XDR-TB, or the relation between drug resistance and fitness of the

bacteria. A better knowledge is also required on the role of efflux pump mechanisms and the

development of clinical drug resistance, or the role of porins, if any, on the intrinsic resistance to

certain antibiotics. It is, thus, quite important to further our knowledge of additional mechanisms

of drug resistance to the available anti-TB drugs. This could have a major impact on the

dynamics of TB transmission and for the discovery and development of new anti-TB drugs.

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 REFERENCES

Adegboyega T.T, Thomas B.T, Agu G.C, Abiodun A.T. (2014) Can Nigeria sustain the fight
against Drug resistant Mycobacterium Tuberculosis? J Microbiol Res x; 4(2) 72-77

Anthony Malinga L , Stoltz A . (2016) Efflux pump mediated second-line tuberculosis drug
resistance . Mycobacterial Dis ;6, DOI: 10.4172/2161-1068.1000222

Alexander, D.C.; Ma, J.H.; Guthrie, J.L.; Blair, J.; Chedore, P.; Jamieson, F.B. (2012) Gene
sequencing for routine verification of pyrazinamide resistance in Mycobacterium
tuberculosis: A role for pncA but not rpsA. J. Clin. Microbiol., 50, 3726–3728.

CDC, Centers for Disease Control and Prevention. (2016) Emergence of Mycobacterium
tuberculosis with extensive resistance to second line drugs–worldwide, 2000–2004.
MMWR; 55; 301–305.

Chandra, P.; Grigsby, S.J.; Philips, J.A. (2022) Immune evasion and provocation by
Mycobacterium tuberculosis. Nat. Rev. Microbiol., 20, 750–766.

Coscolla, M.; Gagneux, S.; Menardo, F.; Loiseau, C.; Ruiz-Rodriguez, P.; Borrell, S.; Otchere,
I.D.; Asante-Poku, A.; Asare, P.; Sanchez-Buso, L.; et al. (2021) Phylogenomics of
Mycobacterium africanum reveals a new lineage and a complex evolutionary
history. Microb. Genom., 7, 000477.

Kwan C.K, Ernst J.D. (2016) HIV and Tuberculosis: a deadly human syndemic. Clin Microbiol
Rev; 24(2) 351-376.

Li, T.; Du, X.; Kang, J.; Luo, D.; Liu, X.; Zhao, Y. (2023) Patient, Diagnosis, and Treatment
Delays Among Tuberculosis Patients Before and During COVID-19 Epidemic—
China, 2018–2022. China CDC Wkly., 5, 259–265.

Migliori, G.B., Centis, R., D., Ambrosio, L.; Spanevello, A.; Borroni, E.; Cirillo, D.M.; Sotgiu,
G. (2012) Totally drug-resistant and extremely drug-resistant tuberculosis: The
same disease? Clin. Infect. Dis., 54, 1379–1380.

Ndjeka, N. (2014) Multi-Drug Resistant Tuberculosis. Strategic Overview on MDR TB care in

SouthAfrica..www.health-e.org.za/2014/03.../presentation-drug-resistant-tb-south-
afri..3-25.

Pasca, M.R., Degiacomi, G.; Ribeiro, A.L., Zara, F., De Mori, P.; Heym, B.; Mirrione, M.;
Brerra, R.; Pagani, L.; Pucillo, L.; et al. (2010) Clinical isolates of Mycobacterium
tuberculosis in four European hospitals are uniformly susceptible to
benzothiazinones. Antimicrob. Agents Chemother., 54, 1616–1618.

Patterson, B. and Wood, R. (2019) Is cough really necessary for TB transmission? Tuberculosis,
117, 31–35.

15
Reddy, V.M., Dubuisson, T., Einck, L., Wallis, R.S.; Jakubiec, W.; Ladukto, L.; Campbell, S.;
Nacy, C.A. (2012) SQ109 and PNU-100480 interact to kill Mycobacterium
tuberculosisin vitro. J. Antimicrob. Chemother., 67, 1163

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.

Shuaib, Y.A., Utpatel, C., Kohl, T.A.; Barilar, I.; Diricks, M.; Ashraf, N.; Wieler, L.H.; Kerubo,
G.; Mesfin, E.A.; Diallo, A.B.; et al. (2022) Origin and Global Expansion of
Mycobacterium tuberculosis Complex Lineage 3. Genes, 13, 990

Tahlan, K., Wilson, R. Kastrinsky, D.B.; Arora, K., Nair, V., Fischer, E., Barnes, S.W., Walker,
J.R.; Alland, D.; Barry, C.E., 3rd; et al. (2012) SQ109 targets MmpL3, a membrane
transporter of trehalose monomycolate involved in mycolic acid donation to the cell
wall core of Mycobacterium tuberculosis. Antimicrob. Agents Chemother., 56,
1797–1809.

WHO, Global Plan to stop TB 2006-2015: Progress Report 2006-2008. 25-28

World Health Organization Global Tuberculosis Report 2012. Geneva, WHO Press, 2012. 41-51

16