Singh., 2020. Mekanisme Resistensi Obat

Journal of Applied Microbiology ISSN 1364-5072
REVIEW ARTICLE
Recent updates on drug resistance in Mycobacterium

tuberculosis
R. Singh1, S.P. Dwivedi2, U.S. Gaharwar3, R. Meena3, P. Rajamani3 and T. Prasad1
1 AIRF & Special Centre for Nano Sciences, Jawaharlal Nehru University, New Delhi, India
2 IFTM University, Moradabad, Uttar Pradesh, India
3 School of Environmental Sciences, Jawaharlal Nehru University, New Delhi, India
Keywords Summary
anti-tubercular drugs, drug resistance, Tuberculosis (TB) along with acquired immune deficiency syndrome and
multidrug drug-resistant tuberculosis,
malaria rank among the top three fatal infectious diseases which pose threat to
Mycobacterium tuberculosis, tuberculosis.
global public health, especially in middle and low income countries. TB caused
Correspondence by Mycobacterium tuberculosis (Mtb) is an airborne infectious disease and one-
Tulika Prasad, Room #14, AIRF, Jawaharlal third of the world’s population gets infected with TB leading to nearly 16
Nehru University, New Delhi 110067, India. million deaths annually. TB drugs are administered in different combinations
E-mail: prasadtulika@hotmail.com; prasadtu- of four first-line drugs (rifampicin, isoniazid, pyrazinamide and ethambutol)
lika@mail.jnu.ac.in which form the core of treatment regimens in the initial treatment phase of 6–
9 months. Several reasons account for the failure of TB therapy such as (i) late
2019/0904: received 7 June 2019, revised 9
diagnosis, (ii) lack of timely and proper administration of effective drugs, (iii)
September 2019 and accepted 13 September
2019 lower availability of less toxic, inexpensive and effective drugs, (iv) long
treatment duration, (v) nonadherence to drug regimen and (vi) evolution of
doi:10.1111/jam.14478 drug-resistant TB strains. Drug-resistant TB poses a significant challenge to TB
therapy and control programs. In the background of worldwide emergence of
558 000 new TB cases with resistance to rifampicin in the year 2017 and of
them, 82% becoming multidrug-resistant TB (MDR-TB), it is essential to
continuously update the knowledge on the mechanisms and molecular basis
for evolution of Mtb drug resistance. This narrative and traditional review
summarizes the progress on the anti-tubercular agents, their mode of action
and drug resistance mechanisms in Mtb. The aim of this review is to provide
recent updates on drug resistance mechanisms, newly developed/repurposed
anti-TB agents in pipeline and international recommendations to manage
MDR-TB. It is based on recent literature and WHO guidelines and aims to
facilitate better understanding of drug resistance for effective TB therapy and
clinical management.
To address this global need, all 194 Member States of

Introduction
World Health Organization (WHO) and the United
Tuberculosis (TB) is a highly infectious disease caused by Nations (UN) unanimously agreed to progress towards
Mycobacterium tuberculosis (Mtb), which primarily affects the goal of ending TB epidemic by 2030 and endorsed
the lungs to cause pulmonary TB and affects other body WHO’s END TB Strategy at the World Health Assembly
parts to cause extra pulmonary TB (Lee and Yeo 2015; in May 2014. The END TB strategy of WHO aims to
Pai et al. 2016; Ravimohan et al. 2018; WHO 2018). It is achieve a world free of TB with zero deaths and suffering
the leading cause of death from single infectious agent, due to TB. This strategy sets interim milestones for 2020,
ranking above HIV/acquired immune deficiency syn- 2025 and 2030 and targets to have 95% reduction in TB
drome (AIDS) (WHO 2018). Prevention of new Mtb deaths and 90% reduction in new incidence of TB cases
infections and their progression to TB disease is critical (new cases per 100 000 population per year) between the
to reduce the burden of disease and death caused by TB. baseline year 2015 and 2035, ensuring that zero families
Journal of Applied Microbiology 128, 1547--1567 © 2019 The Society for Applied Microbiology 1547
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Antibiotic resistance mechanisms in M. tuberculosis R. Singh et al.
face catastrophic costs due to TB by 2035 (WHO 2015; poor nutrition), alcohol abuse, smoking, immigrant sta-
Pai 2015; Matteelli et al. 2018). The Global Tuberculosis tus, co-infection with other diseases (HIV/AIDS, diabetes,
Report is published by WHO every year since 1997 to fungal infection), presence of TB patient in the house etc
provide updated comprehensive information on TB epi- (Singla 2017; Hameed et al. 2018; WHO 2018). The evo-
demic and progress on TB prevention at regional, coun- lution of drug-resistant TB can be controlled by ensuring
try and global levels (Falzon et al. 2017; WHO 2018). In rapid and timely TB diagnosis, adequate infection control
2017, 10 million individuals (58 million men, 32 million in TB treatment facilities, judicious and correct use of
women and 10 million children) with TB infections and drugs for therapy, patient compliance to drug regimen
16 million TB deaths were reported which included 03 and social awareness on TB control and drug regimen
million individuals co-infected with HIV (WHO 2018). (Pinto and Menzies 2011).
Tuberculosis occurs in every country of the world. However, emergence of drug-resistant TB still remains
Three lists of high burden countries (HBCs) have been a challenge to TB therapy and effective disease manage-
defined by WHO for TB, TB/HIV and multidrug-resis- ment and is a major threat to global public health (Rav-
tant TB (MDR-TB) respectively for the first 5 years of iglione and Sulis 2016; WHO 2018). Drug resistance in
END TB strategy (2016–20), wherein at least 48 countries Mtb evolves through several mechanisms which include
appear in one list. The 14 countries present in all three compensatory evolution, epistasis, clonal interference, cell
lists include Angola, China, the Democratic Republic of envelope impermeability, efflux pumps, drug degradation
the Congo, Ethiopia, India, Indonesia, Kenya, Mozam- and modification, target mimicry and phenotypic drug
bique, Myanmar, Nigeria, Papua New Guinea, South tolerance (Saeedi and Hajoj-A 2017; Rojas et al. 2019).
Africa, Thailand and Zimbabwe (WHO 2018). These Understanding the biochemical, genetic and molecular
HBCs annually account for 84% of global TB, 83% of basis of resistance is, therefore, of prime importance to
TB/HIV and 87% of MDR-TB cases respectively (WHO devise innovative therapeutic strategies and combat drug
2018). TB low burden countries are least affected by TB resistance. This review highlights the recent updates on
and annually report very low incidence of active TB dis- existing and in pipeline new/repurposed anti-TB agents,
ease, that is, less than 10 cases per 100 000 population. their mode of action and drug resistance mechanisms in
These are represented by the high income group of coun- Mtb. The knowledge is likely to facilitate better under-
tries such as Canada, USA, Australia, Western Europe standing of drug resistance for effective TB therapy and
and New Zealand (Zammarchi et al. 2014; Byrne et al. clinical management.
2015; Heuvelings et al. 2017; Khazaei et al. 2017; WHO
2018). Around 17 billion individuals, that is, 23% of the
Drug-resistant TB
world’s population are estimated to have latent TB infec-
tion (LTBI) and are at a risk of developing active TB dis- Drug-resistant TB strains emerging in both hospital and
ease during their lifetime. community settings exhibit different levels of drug resis-
The probability of developing TB disease is much tance such as rifampicin resistance (RR), MDR and
higher among individuals with medical conditions that extensive drug resistance (XDR). RR-TB is resistance only
weaken the immune system such as HIV/AIDS, diabetes, towards rifampicin and not to other first- or second-line
cancer, organ transplantation, renal disease, alcohol drugs. MDR-TB is defined as resistance to at least two
abuse, malnutrition, severe fungal infections, tumour most powerful anti-TB drugs, isoniazid and rifampicin. It
necrosis factor alpha (TNF-a) antagonist therapy, tobacco was found that 558 000 TB cases reported worldwide in
use, air pollution, malignancies, an aging population and 2017 were rifampicin resistant (RR-TB) and of these,
many others (Marais et al. 2013; Hameed et al. 2018). 82% were multidrug-resistant TB (MDR-TB). Treatment
The currently recommended treatment for drug-suscepti- for RR-TB and MDR-TB is usually longer, for 18 months
ble TB is a 6–9 month long regimen of combination of or more and consists of selected first-line drugs along
four first-line drugs: isoniazid, rifampicin, ethambutol with different combinations of second-line drugs, which
and pyrazinamide (Lienhardt et al. 2010; Conde and Silva are more expensive and toxic. WHO has reported a glo-
2011; Nasiri et al. 2017; Honeyborne et al. 2019). At least bal success rate of 55% for MDR-TB treatment. XDR-TB
85% of drug-susceptible TB are successfully treated and is a form of TB which is defined as MDR-TB plus resis-
reported regularly to WHO by the 194 Member States. tance to at least one drug from each of the two impor-
However, noncompliance of drug regimen, misuse or tant classes of second-line agents (fluoroquinolones and
misadministration of TB drugs often leads to emergence injectables) used in MDR treatment regimen. This implies
of drug-resistant strains (Nguyen 2016). Other predispos- that it involves resistance to isoniazid and rifampicin, in
ing factors for drug-resistant TB include low socio-eco- addition to resistance towards any of the fluoro-
nomic status (such as employment, education, income, quinolones (such as levofloxacin or moxifloxacin) and to
1548 Journal of Applied Microbiology 128, 1547--1567 © 2019 The Society for Applied Microbiology
R. Singh et al. Antibiotic resistance mechanisms in M. tuberculosis
at least one of the three injectable second-line drugs treatment to LTBI should not get hindered by lack of
(amikacin, capreomycin or kanamycin) (Tabarsi and access to chest radiography, tuberculin skin testing, or
Mardani 2012; Seung et al. 2015). In 2007 in Europe, iso- interferon gamma release assay. The guidelines for LTBI
lated cases of TB with resistance to all first-line and sec- treatment include four options with different combina-
ond-line anti-TB drugs were reported (Migliori et al. tions of doses of rifampicin and/or isoniazid for 3–
2007a; Migliori et al. 2007b; Migliori et al. 2007c). 6 months and the advantage of this shorter duration is
Another study from Iran in 2009 reported a group of 15 patient compliance to treatment regimen (WHO 2018).
patients with resistance to all anti-TB drugs tested (Velay- Active TB disease should always be ruled out by
ati et al. 2009). The authors in these reports respectively screening for symptoms before prescribing preventive
used the terms extremely drug-resistant (XXDR)-TB and treatment. According to WHO guidelines, there are two
totally drug-resistant (TDR)-TB in their studies. Later major groups of anti-TB drugs, Group-1 comprising of
four patients were also reported from India with totally four first-line drugs and Groups-2 comprising of second-
drug-resistant TB (Udwadia et al. 2012). However, a term line anti-TB drugs. The four first-line anti-TB agents that
like ‘totally drug resistant’ is not clearly defined for TB form the core of treatment regimen of drug-susceptible
and therefore, not yet recognized by WHO. Presently TB in new patients (with active TB disease but who have
according to WHO, such cases are also defined as XDR- not undergone prior TB treatment) include isoniazid,
TB, mainly because in vitro drug susceptibility testing rifampicin, pyrazinamide, ethambutol (Tiberi et al. 2018;
(DST) is technically challenging and has limitations. A WHO 2018). Among the first-line drugs, rifampicin, iso-
consensus after thorough study on appropriate methods, niazid and pyrazinamide are bactericidal whereas ethamb-
critical drug concentrations defining resistance, reliability utol is bacteriostatic. More than 90% of patients with
and reproducibility of results, has been reached for con- drug-sensitive TB remain curable in 6 months using oral
ventional DST but only for drugs that define MDR-TB administration of combinations of first-line drugs (Tiberi
and XDR-TB (WHO/HTM/TB/2008a). The reproducibil- et al. 2018). The drug-sensitive TB treatment regimen
ity and reliability of DST for the rest of second-line drugs consists of an intensive phase of 2 months, followed by a
has not been established and still remain to be correlated continuation phase of either 4 or 7 months (total of 6–
with clinical response to treatment. Therefore, WHO rec- 9 months of treatment).
ommendations do not advise to use these results for Mtb resistant to rifampicin and/or other anti-TB drugs
guiding treatment (WHO/HTM/TB/2008b). poses a challenge to public health and patient survival.
Classification of drugs used in susceptible-TB and MDR-
TB treatment regimen, as per WHO guidelines 2016 (Da
Drugs and strategies for improving treatment
Silva 2011; Hoagland et al. 2016; Rendon et al. 2016;
outcome of TB
Gygli et al. 2017; Nasiruddin et al. 2017; Tiber et. al.
An unprecedented acceleration in the rate of decline in 2017; Hameed et al. 2018) is given in Table 1. Treatment
TB incidence is required after 2025 to achieve the End guidelines for drug-resistant TB are updated by the
TB Strategy targets set for 2030 and 2035. This acceler- Guideline Development Group (GDG) of WHO and the
ated rate (an average of 17% per year between 2025 and Group comprises of an International team of experts with
2035) is possible only if the progression from LTBI to broad technical knowledge base. The new guidelines rec-
active TB disease is substantially reduced among the 17 ommend shorter, standardized 9–12 months treatment
billion people already infected worldwide (WHO 2018). regimen in patients with RR/MDR-TB (Wang et al. 2015;
LTBI is defined as a state of persistent immune response Falzon et al. 2017). The grouping of the drugs used for
to Mtb without clinical manifestation of active TB dis- the treatment of MDR/RR-TB and XDR-TB is revised by
ease. Health care interventions to cut the risk of progres- GDG based on the updated evidence reviews on their
sion from LTBI to active TB disease include more effectiveness and safety (World Health Organization
effective drug treatments for LTBI and development of a 2016). The Group-2 drugs forming the ‘core’ second-line
vaccine to prevent reactivation of LTBI in adults. Action components of a longer MDR-TB treatment regimen are
on the broader determinants of TB could also reduce this now classified into four groups (A, B, C and D) (WHO
risk (Lee 2016; WHO 2018). Three priority groups for 2016; Hoagland et al. 2016; Falzon et al. 2017; Gygli et al.
testing and treatment of LTBI have been recommended 2017; Tiberi et al. 2018; Prasad et al. 2018). Most second-
by 2018 guidelines of WHO and these include HIV indi- line drugs exhibit bactericidal activity, although some are
viduals, children below 5 years coming in contact with only bacteriostatic (Mpagama et al. 2013; Farhat et al.
confirmed pulmonary TB cases and clinical risk groups 2016; Falzon et al. 2017; Nasiruddin et al. 2017; Tiberi
with anti-TNF treatment, dialysis, organ or haematologi- et al. 2018). Group-D drugs comprising of add on agents
cal transplantation, silicosis etc (WHO 2018). The which are not components of core MDR-TB regimen are
divided into three subgroups, viz. D1 (first-line anti-TB Bedaquiline or delamanid may be added to the longer
medicines), D2 (bedaquiline and delamanid) and D3 MDR-TB regimen to either replace another second-line
(other agents of uncertain role in MDR-TB treatment). agent or to strengthen it. Carbapenems and clavulanate
According to WHO, only drugs under subgroups A, B, C are used together in treatment. Thioacetazone is used
and D are relevant for MDR-TB treatment, although they only in HIV-negative TB cases (Falzon et al. 2017).
are more expensive and toxic (Tiberi et al. 2018). Group- Table 2 lists the new/repurposed drugs in pipeline (un-
A drugs recommended for MDR-TB treatment regimen der clinical trials) and compounds under in vitro/preclini-
include oral fluoroquinolones such as levofloxacin, moxi- cal study for TB treatment, details of their drug targets
floxacin, gatifloxacin. Group-B drugs for MDR-TB and cellular processes inhibited (Silva et al. 2018; Tiberi
include second-line injectables such as aminoglycoside et al. 2018; WHO 2018). The number of drugs in pipe-
(e.g. kanamycin, amikacin), cyclic peptides (e.g. capre- line has expanded to 20 in the recent months as com-
omycin) and aminoglycoside (streptomycin). Group-C pared to 17 in August 2017. These are presently in
drugs for MDR-TB treatment consist of other core sec- different phases of clinical trials (I, II or III) and include
ond-line agents such as isonicotinic acid derivative/thioa- drugs for treatment of drug-susceptible TB, MDR-TB or
mide drugs (ethionamide/prothionamide), D-cycloserine, LTBI. Of these 20 drugs, 11 are new compounds namely,
derivate of cycloserine (terizidone), iminopherazine (clo- contezolid, delpazolid, GSK-3036656, macozinone, OPC-
fazimine), oxazolidinone (linezolid) (Falzon et al. 2017; 167832, pretomanid, Q203, SQ109, sutezolid, TBA-7371
Tiberi et al. 2018). Subgroup-D1 drugs for MDR-TB and TBI-166 (Silva et al. 2018; Tiberi et al. 2018; WHO
treatment consist of nicotinamide derivative (pyrazi- 2018). Newer fluoroquinolones such as moxifloxacin
namide), ethylene diimino di-1-butanol (ethambutol) (FDA approved in 1999) and gatifloxacin (FDA approved
and nicotinic acid hydrazide (high-dose isoniazid). Sub- in May, 2010) are already in the market. The drug beda-
group-D2 for MDR-TB regimen comprises of quiline was approved by US Food and Drug Administra-
diarylquinoline (bedaquiline) and nitroimidazole (dela- tion (FDA) in 2012 for treatment of MDR-TB and XDR-
manid) (Falzon et al. 2017; Tiberi et al. 2018). Subgroup- TB. Delamanid, known by the trade name Deltyba and
D3 consists of para-amino salicylic acid, semi-synthetic formerly called OPC-67683, was the first in a new class
thienamycin (imipenem), meropenem, b-lactam with b- of drugs called nitroimadazoles to get conditional
lactamase inhibitor (Amoxicillin b-lactam antibiotic with approval in April 2014 by the European Medicines
clavulanate b-lactamase inhibitor) and thiacetazone. The Agency (EMA) and more evidence was needed to confirm
MDR/RR-TB treatment regimen includes at least five its long-term safety and efficacy. Delamanid got approval
effective TB medicines during the intensive phase and from the Japanese Regulatory Authority in July 2014.
consists of pyrazinamide and four second-line TB drugs: WHO released the interim policy guidance on use of
one from Group-A, one from Group-B and at least two delamanid for MDR-TB in October 2014 (Sloan and
from Group-C. If the minimum number of effective TB Lewis 2016). Some studies since 2016 have supported the
drugs cannot be composed as above, an agent from use of combination of bedaquiline and delamanid for
Group-D2 and other agents from Group-D3 may be people with fewer treatment options (Ferlazzo et al.
added. More drugs which can increase the chances of 2018). Seven repurposed drugs in process of further test-
cure may be included if found safe (Falzon et al. 2017; ing include clofazimine, linezolid, levofloxacin, moxi-
Tiberi et al. 2018). If nephrotoxic or hearing loss is floxacin, nitazoxanide, rifampicin (high dose) and
encountered, an injectable agent (Group-B) may be rifapentine (Tiberi et al. 2018). Rifamycin derivatives
replaced by additional agents from Group-C or Sub- such as rifabutin (FDA approved in December, 1992) and
group-D2. The preference for use of oral fluoro- rifapentine (FDA approved in June, 2009) are already in
quinolones is in the order levofloxacin, moxifloxacin and use in the market. Various combinations of treatment
gatifloxacin (Falzon et al. 2017). It is recommended that regimens using these new or repurposed drugs are under
ofloxacin be phased out from MDR-TB regimens and clinical trial phase II or III.
ciprofloxacin be never used due to limited evidence for Other new strategies currently under active investiga-
their effectiveness. Streptomycin may substitute other tion for improving outcomes of TB treatment include
injectable agents, if the other three cannot be used. Two development of next-generation nano-based drug delivery
or more of the following Group-C second-line agents, vehicles using biodegradable polymers, liposomes and
that is, ethionamide (or prothionamide), cycloserine (or microspheres (Hari et al. 2010; Gregory et al. 2013; Wang
terizidone), linezolid and clofazimine (Luthra et al. 2018; et al. 2013; Kim et al. 2015; Lambert et al. 2017; Nasirud-
Falzon et al. 2017) should be included during the inten- din et al. 2017). Table 3 lists the nano-based drug deliv-
sive phase of MDR-TB core regimen, so that the total ery systems, their properties, administration mode and
number of effective second-line TB drugs is at least four. present status of development. Nanocarrier-based drug
Table 1 Classification of drugs used in susceptible TB and MDR-TB treatment regimen, as per WHO guidelines 2016 (Da Silva 2011; Hoagland et al. 2016; Rendon et al. 2016; Gygli et al. 2017;
Nasiruddin et al. 2017; Tiber et. al. 2017; Hameed et al. 2018)
Class Drug name Anti-Mtb activity Target genes Mode of action

R. Singh et al.
Group-1: First-line ORAL

Rifamycin derivative RIF (Rifampicin) Bactericidal rpoB—encodes b-subunit of RNA polymerase Blocks protein synthesis through inhibition of RNA
rpoA—encodes a-subunit of RNA polymerase synthesis by binding to rpoB
rpoC—encodes b0 -subunit of RNA polymerase
Nicotinic acid hydrazide INH (Isoniazid) katG—encodes catalase peroxidase) Pro-drug activation by katG followed by targeting
inhA—encodes NADH-specific enoyl-acyl carrier of inhA and kasA by activated INH leads to
protein (ACP) reductase inhibition of mycolic acid synthesis
kasA—encodes b-ketoacyl ACP synthase
Ndh—encodes NADH dehydrogenase II Binding of activated INH adduct to InhA is an
NADH-dependent enoyl-ACP reductase necessary
for mycolic acid synthesis in Mtb
ahpC encodes Alkyl hydroperoxidase Proposed that ahpC mitigates the added burden
FabG—encodes 3-Oxoacyl (acyl carrier protein) imposed by organic peroxides on Mtb strains
reductase
iniA—encodes INH inducible gene
FadE24—encodes acyl-CoA dehydrogenase
Nicotinamide derivative PZA (Pyrazinamide) pncA—encodes pyrazinamidase Pro-drug activation by pncA to form pyrazinoic acid
which by lowering pH inactivates vital fatty acid
synthase
rpsA—encodes 30S ribosomal protein S1 Pyrazinoic acid (POA), the active form of PZA binds
panD—encodes aspartate decarboxylase to rpsA to inhibit trans-translation by disrupting
Journal of Applied Microbiology 128, 1547--1567 © 2019 The Society for Applied Microbiology
tmRNA interaction
clpC1—encodes ATP-dependent Clp protease ATP- POA blocks synthesis of pantothenate or b-alanine
binding subunit (a precursor for coenzyme A) through inhibition of
panD activity
gpsI—encodes bifunctional protein POA disrupts energy homeostasis through inhibition
polyribonucleotide nucleotidyltransferase (pnpase) of coenzyme A (CoA) molecule (important for all
energy metabolisms)
Ethylene diimino di-1-butanol EMB (ethambutol) Bacteriostatic embC-embA-embB—encodes three homologous, Interacts with three homologous, membrane
membrane associated arabinosyltransferases associated arabinosyltransferases i.e. embC-embA-
embB and targets synthesis and polymerization of
cell wall component arabinan to affect lipid/cell
wall synthesis
embR—encodes transcriptional regulatory protein Also regulates expression of proteins encoded by
rmlD—encodes dTDP-4-dehydrorhamnose INH inducible genes such as iniA and ACP proteins
reductase
Group-2 Second-line oral and injectables
Group-A: Fluoroquinolones (Oral)
(Continued)
Antibiotic resistance mechanisms in M. tuberculosis
1551
Table 1 (Continued)
1552
Fluoroquinolone LFX (levofloxacin) Bactericidal Topoisomerase II (DNA gyrase especially gyrA— Targets DNA replication through inhibition of DNA
(Oral) encoding DNA gyrase subunit A) gyrase
CIP ciprofloxacin)/OFX Bactericidal Topoisomerase II (DNA gyrase) Targets DNA replication through inhibition of DNA
(ofloxacin) gyrase
Newer fluoroquinolone MFX (moxifloxacin)/ Bactericidal Topoisomerase II (DNA gyrase) Inhibits DNA replication through inhibition of DNA
GFX (gatifloxacin) gyrase
Drug prevents resealing of the dsDNA breaks
generating cleaved complexes
Cleaved complexes block bacterial growth
Higher drug concentration lead to release of DNA
breaks from the complexes followed by
chromosome fragmentation and cell death
Group-B: Second-line injectable agents
Aminoglycoside KAN (kanamycin)/AMI Bactericidal rrs—encodes 16S rRNA Blocks protein synthesis through inhibition of
(amikacin) whiB7—encodes transcriptional regulatory protein peptide chain
Cyclic peptide CAP (Capreomycin)/ Bactericidal rrs—encodes 16S rRNA Inhibits protein synthesis
VIO(Viomycin) tlyA—16S/23S rRNA (cytidine-20 -O)-
methyltransferase
eis—aminoglycoside acetyltransferase
whiB7—encodes transcriptional regulatory protein
Aminoglycoside SM (streptomycin) Bactericidal rpsL—encodes ribosomal protein Targets 30S ribosomal subunit
rrs—encodes 16S rRNA Binds to the ribosomal protein and 16S rRNA
gidB—encodes 16S rRNA methyltransferase leading to misreading of mRNA and leads to faulty
protein synthesis/inhibition of protein synthesis
Group-C: Other core second-line agents
Isonicotinic acid derivative/ ETH (Ethionamide)/ Bactericidal ethA—encodes flavin monooxygenase Inhibits mycolic acid synthesis
thioamide drugs PTH (Prothionamide) inhA—encodes enoyl-acyl ACP reductase
Ndh—encodes NADH dehydrogenase II
mshA—encodes glycosyl transferase
ethR—encodes transcriptional repressor protein
kasA—encodes b-ketoacyl ACP synthase
D-Cycloserine CS (D-cycloserine) Bacteriostatic or alr—encodes alanine racemase Inhibits peptidoglycan synthesis
bactericidal ddl—encodes D-alanine-D-alanine ligase
depending on cycA—encodes D-serine/L
the ald—encodes D-alanine/glycine/D-cycloserine proton
concentration at symporter
infection site
(Continued)
R. Singh et al.
Table 1 (Continued)

R. Singh et al.
Derivate of cycloserine TRD (Terizidone) Bacteriostatic alr—encodes alanine racemase Inhibits cell wall synthesis through inhibition of l-
ddl—encodes D-alanine-D-alanine ligase alanine racemase and D-alanine ligase and
impaired peptidoglycan synthesis
Iminopherazine derivative CFZ (Clofazimine) Bacteriostatic Rv0678 (mmpR)—encodes transcriptional repressor Interfering with redox balance, membrane
of drug efflux pump Mmpl5 disbalance and ROS production
Rv2535c (pepQ)—encodes putative cytoplasmic
aminopeptidase
Rv1979c—encodes putative permease
Oxazolidinone derivative LZD (Linezolid) Bactericidal rrl—encodes 23S rRNA Inhibits protein synthesis
rplC—encodes 50S ribosomal protein L3
Group-D: Add on agents (not core MDR-TB treatment regimen components)
Sub group-D1
Nicotinamide derivative PZA (pyrazinamide) Bactericidal As mentioned above As mentioned above
Ethylene diimino di-1-butanol EMB (ethambutol) Bactericidal As mentioned above As mentioned above
Nicotinic acid hydrazide High-dose isoniazid Bactericidal As mentioned above As mentioned above
Sub group-D2
Diarylquinoline TMC207/R207910 Bactericidal atpE—encoding ATP synthase subunit C Inhibits ATP homeostasis
(bedaquiline) Rv0678 (mmpR)—encoding transcriptional repressor
of drug efflux pump Mmpl5
Nitroimidazole OPC-67683 Bactericidal Five Coenzyme F420 genes: Inhibits mycolic acid and protein synthesis
(delamanid) Rv0407 (fgd1)—encoding NADP-dependent
glucose-6-phosphate dehydrogenase
fbiA/B/C—encodes two-electron transfer cofactor
F420
Rv3547 (Ddn)—encodes deazaflavin (cofactor F420)-
dependent nitroreductase
Sub group-D3
Para-amino salicylic acid PAS (Para-amino Bacteriostatic thyA—encodes thymidylate synthase Inhibits folate synthesis
salicylic acid) folC—encodes dihydrofolate synthase
dfrA—encodes dihydrofolate reductase
ribD—encodes dihydrofolate reductase
Semi-synthetic thienamycin IPM/CLN (injectable) Bactericidal Rv2163c (ftsI)—encodes penicillin binding protein 3 Imipenem/meropenem inhibits cell wall synthesis by
comprised of Imipenem (pbpB) binding to penicillin-binding proteins Cilastatin
(carbapenem class of b- prevents renal metabolism of imipenem
lactams) plus cilastatin, a
dehydropeptidase inhibitor/
Meropenem (carbapenem
class of b-lactams)
(Continued)
1553
delivery system aims to achieve reduction in both drug
Inhibits cyclopropanation of cell wall mycolic acids

Inhibits peptidoglycan and thus, cell wall synthesis
dosage and treatment duration (Din et al. 2017). Drugs
encapsulated in nanocarriers facilitate controlled release,
higher bioavailability of drugs and minimum toxicity in
comparison to the common drugs used in free form
(Vyas et al. 2014; Nasiruddin et al. 2017; Lin et al. 2017).
Therefore, complementation of nanotechnology with
proper management can still lead to better efficacy of
even first generation anti-TB drugs (Nasiruddin et al.
2017).
Mode of action
Improved knowledge on the mode of action of anti-TB

drugs and the mechanisms of drug resistance is likely to
facilitate development of better strategies for MDR rever-
sal. Current knowledge on the mechanisms of Mtb drug
resistance is presented in the subsequent section (Palo-
hadAB and hadBC—encodes the FAS-II dehydratase
mino and Martin 2014; Dookie et al. 2018).
Drug resistance mechanisms in Mycobacterium

ponA—encodes Penicillin binding proteins
Pbp—encodes Penicillin binding proteins
complex comprising of hadABC genes
Drug resistance is a major impediment to TB treatment

and poses a challenge to global public health and thera-
blaC—encodes beta lactamase
peutics. Despite the efficacy of anti-TB drugs, there is

emergence of drug-resistant isolates of Mtb. Several
mechanisms facilitate the evolution of drug resistance in
Mtb, such as compensatory evolution, epistasis, clonal
interference, cell envelope impermeability, efflux pumps,
Target genes
drug degradation and modification, target mimicry and

phenotypic drug tolerance (Saeedi and Hajoj-A 2017;
Rojas et al. 2019). Failure in TB treatment may be due to
both intrinsic (naturally occurring high levels of antibi-
otic resistance) and extrinsic (newly acquired mutations)
Anti-Mtb activity
antibiotic resistance. For example, Mtb encodes for a b-

Bactericidal
Bactericidal
lactamase enzyme in its genome and therefore, exhibits

intrinsic resistance to the b-lactam group of antibiotics
(Pinto and Menzies 2011; Shim and Jo 2013; M€ uller et al.
2013; Nguyen 2016). Lengthy treatment of TB often leads
AMX-CLA (Amoxicillin
to noncompliance of patients to drug regimen and results

lactamase inhibitor)
with clavulanate b-
b-lactam antibiotic
TAC (Thiacetazone)
in rapid evolution of Mtb from mono-drug resistant to

MDR and XDR. The primary step to combat drug resis-
Drug name
tance in Mycobacterium is to understand the mechanisms

involved in antibiotic resistance (Fig. 1) (Nguyen 2016;
Kurz et al. 2016).
b-lactamase
Acquired drug resistance

Bacteria usually acquire antibiotic resistance either
through mutations or horizontal gene transfer mediated
with
Table 1 (Continued)
through plasmids, transposon elements or phages. But

Thiacetazone
horizontal gene transfer through mobile genetic elements

inhibitor
b-lactam
is not reported in Mtb. Rather, drug resistance in Mtb

primarily emerges due to mutations in chromosome,
genes encoding drug targets or drug-activating enzymes,
Class
in response to selection pressure of antibiotics (Culyba
Antibiotics (Drugs)
Efflux pumps overexpression Drug-inactivating Drug modification & inactivation

enzyme
p et
um
uxp ta
rg
Effl 30S
ug
dr 50S
d
ifie
od
M pe
nvelo
ie d cell e
if
Mod s / lipids
in
prote
Alteration of drug target Cell envelope impermeability
Inhibition of drug uptake
Figure 1 Schematic diagram showing the drug resistance mechanisms in Mycobacterium tuberculosis. [Colour figure can be viewed at wileyon
linelibrary.com]
et al. 2015; Wintersdorff et al. 2016). Drug-resistant of alkyl hydroperoxide reductase (AhpC). Mutation in
mutants evolve due to continuous exposure to drugs dur- ahpC might have compensated for the fitness cost of
ing long treatment regimen and noncompliance to drug Ser315Thr mutation in katG (encoding catalase peroxi-
regimen. Therefore, drug concentration is a major deter- dase and responsible for converting isoniazid into bioac-
minant of mutations associated with resistance. Tables 1 tive form) (Koch et al. 2014; Saeedi and Hajoj-A 2017;
and 2 list the important genes which are targets for drugs Dookie et al. 2018). Similarly, compensatory evolution
of different classes and Mtb acquires mutations in several resulting in RR was also reported (Koch et al. 2014;
of these genes to confer resistance to antibiotics (Nguyen Saeedi and Hajoj-A 2017; Dookie et al. 2018). Mutation
2016). in rpoB encoding the b-subunit of RNA polymerase was
Below optimal drug concentration, mutations appear reported in 95% clinical isolates which exhibited high
but at the cost of fitness and often results in reduced level RR but at fitness cost. However, mutation S531L
growth, survival and virulence. Several studies have was found in MDR isolates with low or no cost fitness.
demonstrated that some frequently transmitted Mtb Subsequently, whole genome analysis revealed that muta-
strains undergo low or no cost mutations but exhibit tions in neighbouring genes, rpoA and rpoC, compensated
high level drug resistance (Koch et al. 2014; Saeedi and for the loss of fitness mediated by mutation S531L and
Hajoj-A 2017; Dookie et al. 2018). These resistance mech- 30% of MDR-TB cases in HBCs carried mutations in
anisms may develop through compensatory evolution to rpoA and rpoC (Koch et al. 2014; Saeedi and Hajoj-A
modulate fitness. Compensatory evolution is mediated by 2017; Dookie et al. 2018). Another study reported that
acquisition of a second mutation which minimizes the intragenic V615M mutation in rpoB gene resulted in
deleterious effect of the original mutation and allows Mtb increased rate of transcription elongation, which compen-
to increase its fitness and still retain the resistance pheno- sated for defective RNA polymerase activity due to S531L
type. Compensatory evolution can result from either mutation and conferred RR. Alternative mechanisms of
additional or alternative mutations occurring in intra- or fitness compensation might exist in addition to such
extragenic loci (Saeedi and Hajoj-A 2017). Isoniazid-resis- compensatory mutations and the deleterious effect of
tant Mtb isolates showed decreased virulence in guinea mutations may be reduced by altered gene regulation
pig model (Koch et al. 2014; Saeedi and Hajoj-A 2017; (Koch et al. 2014; Saeedi and Hajoj-A 2017; Dookie et al.
Dookie et al. 2018). Studies also demonstrated that co- 2018). Emergence of mutation A1408G in 16S rRNA gene
occurrence of secondary mutations compensated the was accompanied by overexpression of tlyA, encoding a
impaired fitness in Mtb. An example of compensatory methyltransferase and this resulted in methylation of
evolution associated with isoniazid resistance was the neighbouring 16S rRNA at C1409 position, thereby
observed mutation in ahpC which leads to overexpression increasing Mtb fitness. Identification and inhibition of
Table 2 New/repurposed drugs in pipeline (under clinical trials) and compounds under in vitro/preclinical study for treatment of TB (Somoskovi
et al. 2001; Hameed et al. 2009; Leibert and Rom 2010; Da Silva 2011; Wang et al. 2013; Gualano et al. 2016; Nasiruddin et al. 2017; Gygli
et al. 2017; Lambert et al. 2017; Kaufmann et al. 2017; Koch et al. 2018; Hameed et al. 2018; Honeyborne et al. 2019; Xu et al. 2019)
Class Name of drug Cellular process inhibited Phase of development Drug target
Rifamycin derivative RBU (rifabutin) Inhibits protein synthesis Clinical trial phase-III rpoB—encodes b-subunit of
Bacterial DNA-dependent (already in market) RNA polymerase
RNA polymerase (gene
target identical to that of
rifampicin)
RPT (rifapentine) Inhibits protein synthesis Clinical trial phase-III rpoB—encodes b-subunit of
Bacterial DNA-dependent (already in market) RNA polymerase
RNA polymerase (gene
target identical to that of
rifampicin)
Newer fluoroquinolone MFX (moxifloxacin)/ Inhibits DNA replication Clinical trial phase-III Topoisomerase II (DNA gyrase)
GFX (gatifloxacin) through inhibition of (already in market)
DNA gyrase
Drug prevents resealing of
the dsDNA breaks generating
cleaved complexes
Cleaved complexes block
bacterial growth
Higher drug concentration
lead to release of DNA breaks
from the complexes followed
by chromosome fragmentation
and cell death
Diarylquinoline TMC207/R207910 Inhibits ATP homeostasis Clinical trial phase-III atpE—encodes ATP synthase
(bedaquiline) (already in market) subunit C
Rv0678 (mmpR)—encodes
transcriptional repressor of
drug efflux pump Mmpl5
Nitroimidazole OPC-67683 Inhibits mycolic acid Clinical trial phase-III Five Coenzyme F420 genes:
(delamanid) and protein synthesis (already in market) Rv0407 (fgd1)—encoding
NADP-dependent glucose-6-
phosphate dehydrogenase
fbiA/B/C—encodes two-
electron transfer cofactor
F420
Rv3547 (Ddn)—encodes
deazaflavin (cofactor F420)-
PA-824 (pretomanid) Inhibits lipid and protein synthesis Clinical trial phase-III Rv3547 (Ddn)—Coenzyme
Production of reactive nitrogen F420 gene encodes
species in nonreplicating organism deazaflavin (cofactor F420)-
Pyrrole BM212 Inhibits lipid and cell wall synthesis Clinical trial phase-III mmpL3—encodes
Ethylenediamine SQ109 Clinical trial phase-II transmembrane transporter
Oxazolidinone Sutezolid Blocking microbial protein synthesis Clinical trial phase-II rplC—encodes 50S ribosomal
protein L3
LCB01-0371 Clinical trial phase-II Protein synthesis (binds to
(delpazolid) 23S rRNA)
Contezolid Clinical trial phase-I Protein synthesis (binds to
23S rRNA)
(Continued)
Table 2 (Continued)
Class Name of drug Cellular process inhibited Phase of development Drug target
Imidazopyridine Q203 Inhibits ATP synthesis Clinical trial phase-II QcrB—encodes cytochrome
b subunit of cytochrome
bc1 complex
Thiazolides Nitazoxanide Inhibits pyruvate-ferredoxin Clinical trial phase-II Disrupts membrane potential
oxidoreductase (PFOR) and intrabacterial
pH homeostasis
Iminopherazine Clofazimine Interfering with redox balance, Clinical trial phase-III Rv0678 (mmpR)—encodes
derivative/ membrane disbalance and transcriptional repressor of
riminophenazine ROS production drug efflux pump Mmpl5
Rv2535c (pepQ)—encodes
putative cytoplasmic
aminopeptidase
Rv1979c—encodes putative
permease
TBI-166 May be similar to clofazimine Clinical trial phase-I Exact mechanism not known;
may be similar to clofazimine
as both are riminophenazine
i.e. acting as membrane
destabilizing agent leading
to dysfunction of membrane
transporters
Oxazolidinone Linezolid Inhibits protein synthesis Clinical trial phase-II rrl—encodes 23S rRNA
rplC—encodes 50S ribosomal
protein L3
Oxathiazol-2-one GL5 Inhibits proteasome In vitro study Mtb proteasome
compound HT1171
Capuramycin analog SQ641 Inhibits peptidoglycan synthesis Preclinical testing TL-1—encodes translocase
I enzyme
Recombinant IFN-c Aerosol IFN-c Enhances T-helper-1 (Th1) immune Controlled clinical IFN-c initiates bactericidal
response for bactericidal activity trials (phase-I & II) activity through nitric oxide
Benzothiazinone BTZ-043 Inhibits cell wall synthesis through Clinical trial phase-I DprE1—encodes
inhibition of D-arabinofuranose, decaprenylphosphoryl-beta-
a component of arabinogalactan D-ribose oxidase
and arabinomannan DprE2—encodes

decaprenylphosphoryl-2-
keto-beta-D-erythro-pentose
reductase
Potential dehydratase NAS-21 and NAS-91 Decrease in fatty acid and In vitro study Rv0636—encodes
inhibitors mycolic acid synthesis mycobacterial FAS-II
dehydratase enzyme
Phenothiazines Thioridazine and Inhibition of calcium transport In vitro study Ndh—encodes NADH
chlorpromazine and type II NADH dehydrogenase II
Oxaborole GSK 3036656 Inhibition of protein synthesis Clinical trial phase-I Leucyl-tRNA synthetase (LeuRS)
Benzothiazinone OPC-167832 Inhibits cell wall synthesis Clinical trial phase-I DprE1—encodes
TBA-7371 Clinical trial phase-I decaprenylphosphoryl-b-
0
MCZ/PBTZ-169 Clinical trial phase-I D-ribose 2 -oxidase
(macozinone)
such compensatory mechanisms might lead to disruption traits. The net fitness of interactions is termed positive
in drug resistance transmission and provide a strategy for epistasis in case of beneficial phenotype where effect is
improving TB treatment outcomes (Koch et al. 2014; greater than individual mutation and termed negative
Saeedi and Hajoj-A 2017; Dookie et al. 2018). epistasis in case of deleterious phenotype where effect is
Epistasis is necessary for pathogenic bacteria to modify lower than individual mutation. A study reported role of
their fitness cost and occurs when several mutations positive epistasis in emergence of drug resistance in Mtb
interact amongst each other to express new advantageous (Koch et al. 2014; Saeedi and Hajoj-A 2017; Dookie et al.
Table 3 Nano-based drug delivery (Vyas et al. 2014; Lee and Yeo 2015; Nasiruddin et al. 2017; Din et al. 2017)
Type of nano-formulation/ Present status of

Drugs encapsulation Administration development Property
Rifampin, isoniazid Poly(lactide-co-glycolide) Oral/sub cutaneous Efficacy shown in 1. High constancy/longer

and pyrazinamide (PLG) NPS-encapsulated injection animal model time period
Rifampin, isoniazid Wheat germ agglutinin-coated Oral/Aerosol experiments 2. High carrier ability i.e.
and pyrazinamide PLG nanoparticles multiple drugs can be
Ethambutol PLG NPS-encapsulated Oral encapsulated in the matrix
Clofazimine Nano suspension Intravenous 3. Less side effects compared
Rifampicin or isoniazid alone Liposomes encapsulated Respiratory means to conventional drugs
or intravenous route 4. Increased bioavailability
Rifampicin Tween-based microemulsion Oral (slow, sustained and
(oleic acid+phosphate controlled drug release)
buffer+Tween 80+ethanol) 5. Viability of various routes
Rifampin, isoniazid, Loaded in solid lipid Oral of administration like oral
pyrazinamide and ethambutol nanoparticles (SLN- delivery and inhalation
nanocrystalline nanosuspension 6. Minimal side effects and
in water) improved compliance
Isoniazid and pyrazinamide Encapsulated in Tyloxapol Oral
niosome membrane
Rifampicin and gatifloxacin Encapsulated in niosomes Oral
(vesicular liposome like colloidal
particles formed by self-assembly
of non-ionic surfactants and
hydrating mixture of cholesterol
in aqueous medium)
Rifampicin, isoniazid, Alginate nanoparticles loaded Oral
pyrazinamide and ethambutol
Rifampicin, isoniazid, Alginate nanoparticles Oral
pyrazinamide and ethambutol supplemented with chitosan
2018) wherein they showed that a particular combination mutations were detected, three in katG and one in inhA
of mutations in rpoB and gyrA conferred resistance to (Koch et al. 2014; Saeedi and Hajoj-A 2017; Dookie et al.
rifampicin and ofloxacin. Mutation gyrA D94G frequently 2018). After further 5 months, rest all mutations disap-
occurred in XDR strains of Mtb and was associated with peared except the one in katG. Second patient harboured
positive epistasis in Mtb. The Mtb pathogens from differ- rifampicin-sensitive Mtb with mutation in rpoB (L533P)
ent lineages were likely to exhibit different fitness costs but after 18 months, mutation L533P was replaced by
and drug resistance levels. This was supported by various mutation in rpoB (H526Y) leading to RR (Koch et al.
studies which demonstrated the role of epistasis interac- 2014; Saeedi and Hajoj-A 2017; Dookie et al. 2018). The
tions between genetic background and acquired muta- third patient was a relapsed Mtb case and after
tions in conferring different levels of resistance (Koch 11 months of treatment, two unfixed mutations were
et al. 2014; Saeedi and Hajoj-A 2017; Dookie et al. 2018). detected in ethA (L35R and A341E) but no change in sta-
Various mutations may develop simultaneously in a tus of ethambutol resistance was observed. Thus, compe-
single population depending upon the bacterial popula- tition and interchange of mutations associated with drug
tion size, mutation rate and fitness distribution. Clonal resistance can lead to MDR (Eldholm et al. 2014; Saeedi
interference leads to emergence of the most dominant and Hajoj-A 2017).
clone with drug resistance in the population and elimina-
tion of the clone with a lower mutational effect (Eldholm
Intrinsic drug resistance
et al. 2014; Saeedi and Hajoj-A 2017). Intra-host evolu-
tion of Mtb has been observed in in vivo studies. An The evolution of multiple molecular mechanisms in Mtb
interesting example was reported by Sun et al. (2012), has allowed the pathogen to cope up with the cytotoxicity
who isolated seven Mtb strains from three patients. No of antibiotics and other toxic chemicals and lead to the
Mtb drug resistance was observed in the first patient ini- development of intrinsic drug resistance (Nguyen 2016;
tially but after 19 months of treatment, four independent Luthra et al. 2018). The observed high background of
intrinsic resistance limits TB treatment by both existing previously resistant Mtb cell susceptible to other drug
and new antibiotics. The following are the mechanisms classes.
contributing to the overall intrinsic drug resistance in Any defect in enzymes and proteins contributing to
Mtb (Nguyen 2016; Luthra et al. 2018). Mtb cell wall integrity can result in increased susceptibil-
ity to multiple drugs. MurA and MurB are key biosyn-
Impermeability of cell envelope thetic enzymes involved in the biosynthesis of PG (Smith
Mycobacterial cell envelope has an unusual lipid compo- et al. 2013; Nasiri et al. 2017). The naturally occurring
sition and structure which contributes to virulence and antibiotic fosfomycin is a specific inhibitor of MurA and
intrinsic drug resistance (Nguyen 2016). The most recent forms a covalent adduct with a cysteine residue in the
model for mycobacterial cell envelope subdivides it into active sites. By changing the corresponding cysteine resi-
three distinct entities namely outermost layer called cap- due into aspartic acid, Mtb exhibits intrinsic resistance to
sule, cell wall and cell membrane (Nasiruddin et al. fosfomycin (Smith et al. 2013; Nasiri et al. 2017). Pro-
2017). The outer capsule is mainly formed of proteins, teins of antigen 85 (Ag85) complexes are involved in syn-
glucan and little amount of lipids. The cell wall consists thesis of trehalose dimycolate (TDM) which is important
of outer mycomembrane (MM), arabinogalactan (AG) for cell wall integrity in Mtb. Inactivation of Ag85 gene
and inner peptidoglycan (PG). MM has two leaflets, the affects mycolate content and alters Mtb cell envelope per-
outer one formed of lipids such as phospholipids, tre- meability, thus, resulting in enhanced susceptibility
halose mycolates, glycopeptidolipids and lipoglycans and towards both first-line drugs and other broad spectrum
the inner leaflet composed of long-chain mycolic acids antibiotics (Smith et al. 2013; Nasiri et al. 2017). There-
(MA) (Nguyen 2016). The mycolic acid-arabinogalactan- fore, production of TDM by Ag85 is essential for intrinsic
PG polymer forms a hydrophobic layer in association resistance of Mtb. Ag85-specific inhibitors alone or in
with other lipids and cytoplasmic membrane. The combination with other antibiotics could be an effective
periplasmic space separating the cell wall from the mem- TB treatment strategy. Other examples of Mtb proteins
brane lipid bilayer protects the cells from environmental which are involved in cell wall integrity include GlmU,
stresses and acts as permeability barrier for antibiotics MurX, Alr, RmlC, Ddl, Pks12 and accD6 and they have
(Nguyen 2016). Furthermore, presence of wide array of been demonstrated to be attractive targets for develop-
lipids makes the Mtb cell envelope extremely thick, highly ment of anti-TB agents (Smith et al. 2013; Nasiri et al.
hydrophobic and hinders the diffusion of even hydropho- 2017).
bic molecules, which include antibiotics such as rifamy- b-Lactam antibiotics are known to inactivate the essen-
cins, macrolides, fluoroquinolones and tetracyclines tial transpeptidase activity of classical penicillin binding
(Smith et al. 2013; Nasiruddin et al. 2017; Gygli et al. proteins. Mtb possesses D,D-transpeptidases similar to
2017). It is speculated that the rate of diffusion is a func- other bacteria. In addition, Mtb also is reported to have
tion of hydrophobicity of the molecule only till certain five L,D-transpeptidases (LdtMt1 to LdtMt5) which are
extent and beyond a limit, even highly hydrophobic responsible for resistance to b-lactams such as amoxicillin
molecules cannot diffuse readily through Mtb cell envel- and carbapenems. Mtb lacking both LdtMt1 and LdtMt5
ope (Nasiruddin et al. 2017). The role of mycobacterial exhibited susceptibility to amoxicillin and vancomycin
cell envelope lipids in conferring intrinsic drug resistance (Smith et al. 2013; Nasiri et al. 2017). The two penicillin
was well demonstrated using mutants defective in cell binding proteins, PonA1 and PonA2, contribute to
envelope lipids wherein these mutants exhibited increased biosynthesis and homeostasis of cell wall components and
susceptibility to antibiotics (Nguyen 2016). ponA2 mutants showed four to eightfold increase in ß-
Additionally, the physical organization and composi- lactam susceptibility (Smith et al. 2013; Nasiri et al.
tion of the lipids are likely to affect the cell envelope flu- 2017).
idity which in turn can influence drug susceptibilities. Porins are pore forming proteins present on outer lay-
Fluidity in Mtb is assumed to be a function of mycolic ers of cell wall and they facilitate the entry of hydrophilic
acid structure and determined by the length of mycolic compounds, nutrients and small molecules for sustaining
acid and functional groups present (Nasiruddin et al. Mtb viability and replication (Smith et al. 2013; Nasiri
2017). It has been demonstrated in M. smegmatis that et al. 2017; Gygli et al. 2017). There are many antibiotics
exposure to subinhibitory concentrations of ethambutol which can only traverse through cell wall via porins. The
increased the cell envelope fluidity and simultaneous dif- lipidic nature of cell wall and the presence of lower num-
fusion of compounds across cell envelope, thus, increas- bers of water filled porins in the cell wall prevent the per-
ing drug susceptibilities in combination therapy meation of hydrophilic compounds into the bacterial
(Nasiruddin et al. 2017). Therefore, any increase in fluid- cells (Nguyen 2016). Although Mtb encodes two porin
ity using a drug, for example, ethambutol can render a like proteins OmpA and Rv1698, the role of porins in
uptake of antibiotics and susceptibility has not been streptomycin and tetracycline in Mtb (Nasiruddin et al.
directly established in Mtb (Smith et al. 2013; Nasiri et al. 2017). Efflux pumps play a vital role in isoniazid and RR
2017). especially when no mutations are involved (Wang et al.
2013). Mutations associated with isoniazid resistance were
Drug efflux reported in 15 unique gene regions, the most frequently
The transport of anti-TB drugs across the human and being furA-katG, fabG1-inhA and ahpC-oxyR. Mutations
bacterial membranes affects the local and systemic con- were also reported in efpA, fadE24, iniA, iniB, iniC, kasA,
centration of the drugs and leads to a major hindrance in nat, ndh, Rv1772, Rv1592c, Rv0340 and srmR genes (Lee
TB treatment. Drug efflux pump proteins constitute an et al. 1999; Seifert et al. 2015; Narang et al. 2017;
active efflux mechanism which expels the drug molecules Hameed et al. 2018; Liu et al. 2019). SMR transporter,
entering the bacterial cells (Fig. 2) (Piddock 2006; Blair Mmr was identified in Mtb and found to confer in vitro
et al. 2015; Nguyen 2016; Nasiruddin et al. 2017). These resistance to acriflavine, erythromycin and ethidium bro-
efflux pump proteins are responsible for intrinsic resis- mide (Nguyen 2016; Nasiruddin et al. 2017). Around 15
tance in Mycobacteria towards many anti-TB drugs such putative RND transmembrane proteins were reported in
as fluoroquinolones, tetracycline, aminoglycosides. These Mtb (Wang et al. 2013; Narang et al. 2017; Hameed et al.
proteins are membrane spanning proteins which play an 2018; Liu et al. 2019) and since these proteins exhibited
important role in bacterial metabolism, physiology, trans- characteristics specific to Mycobacteria, they were called
port of nutrients, toxins, wastes or signalling molecules mycobacterial membrane proteins large (mmpL) (Melly
through the cell envelope and active efflux of antibiotics and Purdy 2019). The putative RND transporter,
from bacteria to confer MDR (Nasiruddin et al. 2017). mmpL17 conferred in vitro resistance to isoniazid (Wang
Drug efflux pumps in Mycobacteria can be grouped into et al. 2013; Narang et al. 2017; Hameed et al. 2018; Liu
five superfamilies namely, (i) ATP-binding cassette (ABC) et al. 2019). Although MATE transporters are common in
superfamily, (ii) major facilitator superfamily (MFS), (iii) Escherichia coli and Vibrio sp., they were not reported in
small multidrug resistance (SMR) family, (iv) resistance- Mtb (Wang et al. 2013; Narang et al. 2017; Hameed et al.
nodulation-cell division (RND) superfamily, and (v) mul- 2018; Liu et al. 2019).
tidrug and toxic compound extrusion (MATE) family Two mycobacterial transporters encoded by IniBAC
(Wang et al. 2013). ABC pumps are primary transporters and EfpA are negatively regulated by the transcriptional
using ATP as energy source whereas MFS, SMR, RND regulator Lsr2. IniBAC confers resistance to isoniazid and
and MATE efflux pumps are secondary transporters using ethambutol whereas EfpA is nonspecific MDR transporter.
proton motive force (H+ or Na+) to efflux out drugs The transcriptional control of IniBAC and EfpA by Lsr2
(Nguyen 2016; Nasiruddin et al. 2017). ABC transporters was induced by isoniazid and ethambutol and indicated a
represent 25% of entire genome of Mtb and at least 12 functional evolution towards antibiotic resistance (Smith
putative transporters have been identified which include et al. 2013; Nasiri et al. 2017; Hameed et al. 2018). Tap, a
Rv0194, Rv1218c-Rv1217c, Rv1273c-Rv1272c, Rv1348- transporter of aminoglycosides and tetracycline is regu-
Rv1349, Rv1456c-Rv1457c-Rv1458c, Rv1473, Rv1667c- lated by the MDR regulatory protein WhiB7. Expression
Rv1668c, Rv1686c-Rv1687c, Rv1819, Rv2477, Rv2688c- of WhiB7 and Tap was reported to be induced in presence
Rv2687c-Rv2686c and drrA-drrB-drrC (Wang et al. 2013). of tetracycline, streptomycin or erythromycin (Smith et al.
The role of ABC pumps in clinically relevant resistance is 2013; Nasiri et al. 2017; Hameed et al. 2018). Upon expo-
yet to be established (Wang et al. 2013). Up to 20 poten- sure to isoniazid and rifampicin, overexpression of
tial MFS transporters have been identified in Mtb which Rv1258c (Tap) was found in clinical MDR-TB isolates,
include Rv0037c, Rv0191, Rv0783c, Rv0849, Rv1250, which might be responsible for clinical drug resistance
Rv1258c, Rv1410c, Rv1634, Rv1877, Rv2333c, Rv2456c, (Liu et al. 2019). Furthermore, point mutations (V219A
Rv2459, Rv2846c (efpA), Rv28994, Rv3239c, Rv3728 and and S292L) were identified in efflux pump Rv1258c (Tap)
Rv1747 (Wang et al. 2013; Ghajavand et al. 2019). Antibi- and reported to play an important role in conferring drug
otic stress induces expression of efflux pumps in clinical resistance in clinical isolates to multiple drugs including
Mtb strains (Wang et al. 2013), for example, under isoni- isoniazid, pyrazinamide and streptomycin (Liu et al.
azid and rifampicin stress, the efflux pumps overex- 2019). Overexpression of 11 drug efflux pump genes
pressed were jefA, drrA, drrB, efpA, mmr, Rv1217-Rv1218. (efpA, Rv0849, Rv1250, P55 (Rv1410c), Rv1634, Rv2994,
Increased expression of MFS pump, jefA, leads to resis- stp, Rv2459, pstB, drrA and drrB) was significantly found
tance towards isoniazid, streptomycin and ethambutol. to be higher in nine clinical MDR isolates than in 10 clini-
MFS pumps, Tap and LfrA confer resistance to tetracy- cal pan-sensitive isolates (Li et al. 2015). Additionally,
cline and fluoroquinolones (Wang et al. 2013). MFS multiple efflux pumps including Tap were overexpressed
pump P55 encoded by Rv1410c confers resistance towards in Mtb residing in host granulomas indicating that these
Drug extrusion controlling the overexpression of drug efflux pumps

(Wang et al. 2013; Narang et al. 2017; Hameed et al.
2018; Liu et al. 2019). Drug efflux pumps thus present a
Out promising target for designing novel anti-TB drugs for
treatment and reversal of MDR through efflux pump
inhibition. A recent study designed hybrid efflux pump
inhibitor by fusion of verapamil with phenothiazines and
reported effective inhibition of drug efflux pumps (Smith
et al. 2013; Nasiri et al. 2017; Hameed et al. 2018).
Drug degradation and modification

In
Drug degradation and modification are the most well
Drug import
studied mechanisms for drug resistance in Mtb. Several
Figure 2 Schematic diagram showing the drug efflux mechanisms in enzymes produced by Mtb have evolved to modify or
Mycobacterium tuberculosis. [Colour figure can be viewed at wileyon degrade different classes of antibiotics such as aminogly-
linelibrary.com] cosides, b-lactams and macrolides (Smith et al. 2013;
Nguyen 2016). Bacterial transpeptidases are enzymes
pumps might be contributing to drug tolerance in latent involved in PG cross-linking and thus, essential for cell
TB (Smith et al. 2013). Single nucleotide polymorphisms wall synthesis. Penicillin-binding proteins (PBPs), a
(SNPs) were identified in several efflux pump genes group of transpeptidases required for the assembly of
(Rv0194, Rv1217, Rv1258c, Rv1273, Rv1877, Rv1250 and the PG network, are characterized by their binding affin-
Rv2688) in clinical XDR-TB isolates (Liu et al. 2019). ity for penicillin (b-lactam antibiotics). b-Lactam antibi-
Under isoniazid stress, most efflux pumps were overex- otics are important classes of antibacterial compounds
pressed in MDR clinical isolates which carried the wild- which target the bacterial transpeptidases and disrupt
type katG, inhA and oxyR-ahpC associated with isoniazid cell wall synthesis, causing cell death. b-Lactamases, also
resistance (Li et al. 2015). Interestingly, one MDR isolate known as penicillin resistance enzymes render these
carried a mutation in rpoB which confers RR but katG, antibiotics ineffective by hydrolysing the b-lactam ring
inhA and oxyR-ahpC were found intact; this suggested (Nguyen 2016). Mtb produces Ambler class-A b-lacta-
that efflux pumps rather than mutations alone were mase encoded by blaC gene, which causes b-lactam
responsible for observed isoniazid resistance (Caws et al. resistance. Mtb also encodes at least three more b-lacta-
2006; Smith et al. 2013; Li et al. 2015; Nasiri et al. 2017; mases, namely BlaS, Rv0406c and Rv3677c but these pos-
Narang et al. 2017; Maningi et al. 2018; Hameed et al. sess lower b-lactamase activities (Nguyen 2016). The b-
2018; Liu et al. 2019; Kardan et al. 2019). In another lactam drugs have virtually no effect on Mtb. Several
study, mutations were reported within Rv0678-encoded other factors also contribute to ineffectiveness of b-lac-
transcriptional repressor of MmpL5 (RND transporter), tams and these include impermeable cell wall and low
which resulted in MmpL5 overexpression and clofazimine affinity of PBPs for b-lactams. The genome of Mtb has
resistance (Hameed et al. 2018). In a study on XDR four PBPs which can bind to b-lactams at clinically
strains, SNPs were reported to be associated with ABC achievable concentrations only (Smith et al. 2013;
and MFS transporters such as Rv2688c, Rv0194, Rv2937 Nguyen 2016; Nasiruddin et al. 2017). Low permeability
(drrB), Rv2936 (drrA) and Rv1634 (Smith et al. 2013; of cell wall results in low target accessibility by antibi-
Nasiri et al. 2017; Narang et al. 2017; Hameed et al. 2018; otics and low affinity of PBPs does not allow the bind-
Liu et al. 2019). Another research group reported high ing of the drugs to the target (Nguyen 2016; Nasiruddin
level of expression of the Rv0933c-encoded PstB pump of et al. 2017). Carbapenems, for example, meropenem
ABC transporter family in response to fluoroquinolone belong to b-lactam class of antibiotics and are generally
treatment, suggesting that the expression of PstB is associ- considered resistant to b-lactamase activities of most
ated with fluoroquinolone resistance (Smith et al. 2013; pathogenic bacteria but Mtb BlaC exhibits broad spec-
Nasiri et al. 2017; Hameed et al. 2018). Overexpression of trum hydrolysis activity towards all b-lactams (Smith
MFS Tap efflux pumps has been found to be associated et al. 2013; Nguyen 2016; Nasiruddin et al. 2017).
with kanamycin resistance (Smith et al. 2013; Nasiri et al. Clavulanic acid is an inhibitor of b-lactamase which also
2017; Hameed et al. 2018). remains less effective against BlaC in Mtb. Carbapenems
These findings suggest that efflux pumps strongly con- are hydrolysed by b-lactamases in Mtb, but the reaction
tribute towards development of drug resistance in Mtb. proceeds slowly. Meropenem showed good anti-Mtb
Therefore, it is important to understand the mechanisms activity in vitro in combination with clavulanic acid
against drug-resistant strains. The meropenem-clavulanic of bacterial ribosomal RNA and prevent translocation of
acid combination was found active against nonreplicat- peptidyl-tRNA, thus inhibiting protein synthesis and
ing bacilli (Smith et al. 2013; Nasiruddin et al. 2017). mycobacterial growth. Mtb is inherently resistant to lin-
Antibiotics are rendered inactive by their chemical cosamides and macrolides. In Mtb, erm encodes ery-
modifications such as methylation and acetylation, which thromycin resistance methylase which methylates a
further prevent the binding of antibiotic to target protein specific site in the 23S ribosomal RNA to alter the drug
and lead to antibiotic resistance. Mycobacterial modifying binding site and inhibits the binding of macrolides
enzymes modify the antibiotics by addition of chemical (Nguyen 2016; Munita and Arias 2016). Erm37 alters
groups on specific sites of the antibiotic (Smith et al. ribosomal structures and reduces binding of macrolides
2013; Nguyen 2016; Nasiruddin et al. 2017). Aminoglyco- to ribosomes. The mfpA gene encoding pentapeptide
sides/cyclic peptides are antibiotics used for MDR-TB repeat proteins binds to DNA gyrase and offers protec-
treatment. Aminoglycosides resistance in Mycobacteria is tion from the biocidal action of quinolones, thus confer-
caused by modifying enzymes which are encoded by ring quinolone resistance in Mtb. Resistance to certain
genes on the chromosomes (Nguyen 2016). Acetyltrans- antibiotics in Mtb can also be due to loss of methylation
ferase and phosphotransferase are two main classes of (Nguyen 2016; Munita and Arias 2016). The gene tlyA
aminoglycoside-modifying enzymes in Mycobacteria encodes rRNA methyltransferase and loss of methyltrans-
(Ramirez and Tolmasky 2010; Labby and Tsodikova ferase activity yields an unmethylated ribosome which
2013). N-acetyltransferase was identified in genome of confers resistance to capreomycin and viomycin (Nguyen
Mtb and the best biochemically characterized aminogly- 2016; Munita and Arias 2016). Another gene GidB
coside-modifying enzyme is aminoglycoside N-acetyl- methylates 16S rRNA and inactivation of this activity
transferase (AAC 20 ) which is capable of acetylation of all results in streptomycin resistance. The RNA polymerase
known aminoglycosides bearing 20 amino group, such as binding protein A (RbpA) binds to RNA polymerase and
neomycin, ribostamycin, kanamycin, gentamycin and prevents binding of rifampicin, thus conferring RR
tobramycin (Ramirez and Tolmasky 2010; Labby and (Nguyen 2016; Munita and Arias 2016).
Tsodikova 2013). The acetylation of various aminoglyco- Molecular mimicry of the drug targets is a unique
sides/cyclic peptide antibiotics by enhancing intracellular strategy employed by Mtb to nullify the action of fluoro-
survival protein (encoded by Eis) is the best described quinolones (Drlica et al. 2009; Tao et al. 2013). The bac-
example for drug inactivation by enzymatic modification. tericidal fluoroquinolones act by inhibiting DNA
Eis is able to acetylate and inactivate both second-line replication, transcription and DNA repair. They bind to
injectable aminoglycoside antibiotic kanamycin A and DNA gyrase or topoisomerase in DNA complexes and
cyclic peptide antibiotic capreomycin (Chen et al. 2012; inhibit resealing of fragmented DNA strands, resulting in
Houghton et al. 2013; Gygli et al. 2017). Mutations in DNA degradation and cell death (Drlica et al. 2009; Tao
the promoter of Eis sometimes lead to over expression et al. 2013). The MfpA (Mycobacterium fluoroquinolone
and confer low-level resistance to kanamycin but not to resistance protein A) resembles B form DNA in shape,
amikacin. Whether Eis over expression leads to clinical size and surface and this mimicry of target site results in
resistance to capreomycin is yet to be established. The binding of DNA gyrase to MfpA, thus inhibiting the fluo-
over expression of Eis might be the first step towards roquinolone binding to DNA gyrase (Drlica et al. 2009;
evolution of high resistance towards aminoglycoside/cyc- Tao et al. 2013). Acquired resistance to fluoroquinolones
lic peptide in the future (Chen et al. 2012; Houghton results from mutations in gyrA and gyrB, genes encoding
et al. 2013; Gygli et al. 2017). Eis protects Mtb from host DNA gyrase whereas intrinsic resistance to the same class
immunity and helps in survival of the pathogen in host of antibiotics has been mapped to MfpA. MDR strains of
macrophages. Therefore, Mtb displays co-evolution of vir- Mtb thus, develop the novel mechanism of target mimi-
ulence and antibiotic resistance (Chen et al. 2012; cry to evade cell killing by antibiotics such as fluoro-
Houghton et al. 2013; Gygli et al. 2017). quinolones which target DNA gyrase (Tao et al. 2013;
Nguyen 2016).
Targets alteration and target mimicry
Mtb develops intrinsic drug resistance to important
Phenotypic drug tolerance
antibiotics also by drug target modification which can
prevent binding of antibiotic to target site. Binding of Treatment of TB is very lengthy and exhaustive. The abil-
antibiotics such as lincosamides, macrolides and strepto- ity of a small subpopulation of Mtb cells to tolerate the
mycin is reduced by such target alterations in Mtb (Smith antibiotics and survive the duration of treatment
et al. 2013; Nguyen 2016; Munita and Arias 2016). These increases the duration of the TB treatment. The cells with
drugs reversibly bind to a specific site within 50S subunit this epigenetic drug tolerance are referred to as
‘persisters’ and they are physiologically or metabolically ATP levels, increased lipid metabolism and enhanced
inactive. The persisters and their susceptible counterparts multidrug tolerance; however, certain features may differ
are genetically identical and on restoration of normal depending on inducers (Lipworth et al. 2016; Trastoy
environment, the persisters get metabolically active to et al. 2018). Formation of persisters is considered as an
again become susceptible cells (Zhang and Barer 2012; intrinsic characteristic of bacterial populations and desig-
Smith et al. 2013; Maisonneuve and Gerdes 2014; Nguyen nated to ensure the survival of subpopulations of cells at
2016). The persisters survive the antibiotic treatment by the expense of growth in adverse conditions including
acquiring dormancy, that is, nonreplicating state, which presence of antibiotics.
has very low or almost absent metabolic activity. Dor-
mancy is characterized by reversible metabolic shut down,
Conclusion
suspension of physiological functions, slow growth rate,
inability to grow on solid medium, no replication, loss of Dramatic increase in global incidence of TB and emer-
acid fastness, tolerance to antibiotics and accumulation of gence of drug resistance in Mtb poses a significant chal-
triglycerides within intracellular lipid bodies. This non- lenge to TB treatment and global public health. By
replicating state or dormancy of the pathogen leads to nature, Mtb is endowed with natural intrinsic resistance
asymptomatic infection, that is, without any apparent to most antibiotics but often it also acquires resistance
disease and is called latent TB (Lipworth et al. 2016). The in response to antibiotics. The combinations of intrinsic
latent TB is difficult to eradicate despite host defences and acquired drug resistance mechanisms which include
and drug treatment. Unlike intrinsic and acquired drug genetic mutations, chromosomal alterations, imperme-
resistance, which directly involves genetic or chromoso- ability of cell envelope, drug efflux, drug degradation
mal mutations, the phenotypic tolerance of the Mtb cells and modification, target alteration and target mimicry
involves only reduced metabolic or physiological activities render the Mtb cells resistant to most classes of antibi-
(Smith et al. 2013; Nguyen 2016). To summarize, the otics. Newly acquired mutations and sequential chromo-
pathogenic bacteria attain state of dormancy and shut somal accumulation of such mutations help the bacteria
down most metabolic activities, increasing their tolerance to evolve resistance towards available antibiotics. MDR
to antibiotics which are otherwise lethal to replicating strains further stabilize transmissibility by regaining fit-
bacilli and this phenomenon is defined as phenotypic ness through acquired compensatory mutations. There-
drug tolerance (Gomez and McKinney 2004; Gengen- fore, even after arrival of new anti-TB drugs in the
bacher and Kaufmann 2012). Most of the antibiotics used market, there is always a continuous new threat arising
against TB are able to kill 99% of bacterial cells and only from emergence of MDR and XDR strains. In addition
the persister cells survive due to their low metabolic to intrinsic and acquired drug resistance in Mtb, the
activity. The low metabolic activity in persisters reduces transition from metabolically active, replicating form to
the requirement of cellular proteins which are targets of dormant, nonreplicating form leads to phenotypic drug
antibiotics. This correlates with transcriptomic analyses tolerance and serves as a recalcitrant element in TB ther-
which demonstrated reduced production of these antibi- apy. In the recent years, due to the advances in geno-
otic target proteins in nonreplicating dormant Mtb (Lewis mics and biology, our knowledge on the remarkable
2008; Nguyen 2016; Nasiruddin et al. 2017). According to diversity of mechanisms of antimicrobial resistance in
reports, the bacteria isolated from relapsed or latent TB Mtb has greatly increased. However, despite substantial
patients displayed higher tolerance towards first-line TB progress, there is still scope for further elucidation of
drugs like isoniazid, rifampicin and ethambutol than the molecular basis of antimicrobial resistance in this
drug-sensitive isolates from other patients and this drug group of bacteria. These mechanisms of drug resistance
tolerance was only phenotypic (Nguyen 2016). and drug tolerance limit the use of available antibiotics
Several in vitro models have been established to study in therapy and also impede development of new anti-TB
the relationship between phenotypic drug tolerance and drugs. The best hope for the future is greater under-
low metabolic activity observed during latency in host. standing of exact mechanisms of antimicrobial resistance
The environmental stresses which induce latency in vivo in Mtb to further improve the therapeutic outcomes in
have also been used in vitro to form dormant-like Mtb TB patients. This review summarizes the progress on
cells and these include hypoxia (oxygen depletion), nutri- anti-tubercular agents (existing/newly developed/repur-
ent starvation (e.g. phosphate/nitrogen limitation), antibi- posed), their mode of action and Mtb drug resistance
otics (D-cycloserine) and acidification of medium (low mechanisms. It is based on recent literature and WHO
pH) (Gengenbacher and Kaufmann 2012; Gold and guidelines and aimed to facilitate better understanding
Nathan 2017). All these models share common features of drug resistance for effective TB therapy and clinical
such as reduced respiration, reduced metabolism, reduced management.
Drlica, K., Hiasa, H., Kerns, R., Malik, M., Mustaev, A. and
Author contributions
Zhao, X. (2009) Quinolones: action and resistance
Richa Singh and Tulika Prasad conceived and drafted the updated. Curr Top Med Chem 9, 981–998.
manuscript. All authors read and approved the final Eldholm, V., Norheim, G., von der Lippe, B., Kinander, W.,
manuscript. Dahle, U.R., Caugant, D.A., Manns aker, T., Mengshoel,
A.T. et al. (2014) Evolution of extensively drug-resistant
Mycobacterium tuberculosis from a susceptible ancestor in
Acknowledgements a single patient. Genome Biol 15, 490.
Falzon, D., Sch€unemann, H.J., Harausz, E., Gonzalez-Angulo,
T.P. acknowledges Indian Funding Agency—Indian
L., Lienhardt, C., Jaramillo, E. and Weyer, K. (2017)
Council of Medical Research [5/8/5/15/2012-ECD-I World Health Organization treatment guidelines for drug-
(2012-26130)] and R.S. gratefully thanks Indian Council resistant tuberculosis, 2016 update. Eur Respir J 49,
of Medical Research (ICMR) for the award of Junior 1602308.
Research Fellowship. Farhat, M.R., Jacobson, K.R., Franke, M.F., Kaur, D., Sloutsky,
A., Mitnick, C.D. and Murray, M. (2016) Gyrase
Conflict of Interest mutations are associated with variable levels of
fluoroquinolone resistance in Mycobacterium tuberculosis.
The authors declare no conflict of interest. J Clin Microbiol 54, 727–733.
Ferlazzo, G., Mohr, E., Laxmeshwar, C., Hewison, C., Hughes,
J., Jonckheere, S., Khachatryan, N., De Avezedo, V. et al.
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Journal of Applied Microbiology ISSN 1364-5072

Recent updates on drug resistance in Mycobacterium

To address this global need, all 194 Member States of

Class Drug name Anti-Mtb activity Target genes Mode of action

Group-1: First-line ORAL

Class Drug name Anti-Mtb activity Target genes Mode of action

delivery system aims to achieve reduction in both drug

Inhibits cyclopropanation of cell wall mycolic acids

Improved knowledge on the mode of action of anti-TB

mino and Martin 2014; Dookie et al. 2018).

Drug resistance mechanisms in Mycobacterium

complex comprising of hadABC genes

Drug resistance is a major impediment to TB treatment

peutics. Despite the efficacy of anti-TB drugs, there is

drug degradation and modification, target mimicry and

antibiotic resistance. For example, Mtb encodes for a b-

lactamase enzyme in its genome and therefore, exhibits

to noncompliance of patients to drug regimen and results

in rapid evolution of Mtb from mono-drug resistant to

tance in Mycobacterium is to understand the mechanisms

Acquired drug resistance

through plasmids, transposon elements or phages. But

horizontal gene transfer through mobile genetic elements

is not reported in Mtb. Rather, drug resistance in Mtb

in response to selection pressure of antibiotics (Culyba

Efflux pumps overexpression Drug-inactivating Drug modification & inactivation

Inhibition of drug uptake

and arabinomannan DprE2—encodes

Type of nano-formulation/ Present status of

Rifampin, isoniazid Poly(lactide-co-glycolide) Oral/sub cutaneous Efficacy shown in 1. High constancy/longer

Drug extrusion controlling the overexpression of drug efflux pumps

Drug degradation and modification

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