biology

The Cost of TB Resistance

medicine

Drug-resistant
tuberculosis is more
dangerous than
ever before
by Kathleen Jia

F
or most people, coughing and sneezing may rarely be
acknowledged beyond a perfunctory “bless you”, but
these symptoms are very serious for patients suffering
from tuberculosis. Often thought of as a disease of
the past, tuberculosis is actually a major health problem in
the world today. A Stanford research project recently made
progress toward a better understanding of tuberculosis (TB)
and multi-drug resistant tuberculosis (MDR-TB). Led by
Stanford epidemiologists Gary K. Schoolnik and Peter M. Small
(now at the Bill and Melinda Gates Foundation), Associate
Professor of Biological Sciences Brendan J. M. Bohannan,
former postdoctoral fellow Sebastien Gagneux and graduate
student Clara Davis Long, the study examined a long-held belief
that bacteria with drug-resistant mutations are at a competitive
disadvantage compared to drug-susceptible bacteria. Results of
the study, however, revealed that some types of mutations carry
no competitive cost.
“We have to do everything possible to
prevent the emergence of drug resistance
in the first place.” - Gagneux
Tuberculosis Today
According to the World Health Organization, one-third
of the world’s population is currently infected with the TB
bacillus, although most cases are dormant. Approximately
1.7 million people die from TB every year, making it the
second leading cause of death from infectious disease after
AIDS. In fact, HIV/TB co-infection is dismayingly common
in areas with high HIV infection. Drug-resistant TB arises
mainly in areas lacking proper control programs, where
health care workers may administer improper treatment
or fail to ensure that patients complete the whole course of
treatment.
Although tuberculosis is a curable disease with a high
survival rate, MDR-TB is much more difficult and expensive
to treat. Drug-susceptible TB is treated with a combination
of two to four powerful first-line drugs over a period of 6-9
months. If TB develops resistance to the two most powerful
drugs rifampin and isoniazid, then it is considered MDR-TB.
MDR-TB treatment requires expensive and toxic second-line
drugs for a period of two years. Despite the long treatment,
the cure rate of MDR-TB is only about 50%. Strains that are
resistant to a single drug have been documented in every
country, and strains of TB resistant to all major anti-TB drugs
have been found. For example, XDR-TB, or Extensive Drug
Resistant TB (also referred to as Extreme Drug Resistance)
is MDR-TB that is also resistant to at least three of the six
classes of second-line drugs. XDR-TB may be virtually
untreatable with the TB drugs that are available today.
Clinical TB vs Lab-Grown TB
Dr. Gagneux describes the source of clinical TB used for
the recent study comparing the fitness of drug-sensitive TB
and drug resistant TB. “We took advantage of a long-term
study of active tuberculosis in San
Francisco which started in 1991. At
the time, an outbreak of disease swept
through the City and Drs. Schoolnik
and Small began collecting samples
from every TB case in San Francisco
both before and after treatment. Based
on this database, we were able to identify ten patients who
had developed drug resistance during their treatment and
used their stored TB isolates in our study.”
Previous data using lab-grown Mycobacterium
tuberculosis, the bacteria responsible for TB, supports the

20 stanford scientific

Chest x-rays are one of the few reliable ways of diagnosing tuberculosis.
belief that antibiotic resistance often causes reduced
competitiveness as compared to drug-susceptible strains.
However, current research looking at TB from patients
draws a different conclusion. This research measured the
competitive fitness of clinical bacterial strains resistant to the
powerful first-line drug rifampin against their drug-sensitive
ancestors. Clinical MDR-TB with Greater Fitness than TB
1.7 million people die from TB every year, making it the second-
leading cause of deaths among infectious diseases after AIDS
DNA fingerprinting methods were used to show that resistant
(MDR-TB) and non-resistant (TB) strains from the same
patient were of common ancestry. Rifampin resistance is
caused by mutations in rpoB, the gene encoding a subunit of
RNA polymerase necessary for gene transcription. Each of
the mutated strains was distinct, but five had an rpoB S531L
mutation, replacing the 531st amino acid serine with leucine.
The remaining five had other rpoB mutations. Results of the
study showed that all mutants without the S531L mutation
had relative fitness less than 1.0, meaning they were less
competitively fit than wild-type, drug sensitive TB ancestors.
In contrast, four of the five clinical strains with the rpoB S531L
mutation had a relative fitness greater than or equal to 1.0,
meaning they were more or
equally fit than their drug
sensitive TB ancestors.
These four strains were
the only rifampin-resistant
mutants found to have no
fitness cost.
Culture with TB strains
layout design: Jason Shen
biology
“A major point in the study is that this low cost +
medicine
mutation exists independent of the strain’s genetic
background, whereas the fitness effects of other
rpoB mutations depends on the strain background,” said
Dr. Gagneux. The results of the study could be explained
in two ways. There may be no fitness cost associated with
the S531L mutation. Alternatively, enough time had passed
after this mutation for compensatory mutations to arise that
ameliorate the high fitness cost. The second explanation
is supported by Gagneux’s data, because clinical mutants
taken from patients had a competitive fitness of 1.04, which
is greater than the laboratory-derived S531L mutants that
had an average competitive fitness of 0.93.
The Future of TB
The results of this research have implications for predictions
about the future of TB worldwide. When given time, drug-
resistant TB will mutate further to gain increased fitness. As
Dr. Gagneux describes it, “Our research also shows we have
to do everything possible to prevent the emergence of drug
resistance in the first place. Some people think that to stop
drug resistance, we only need to stop drug treatment and
wait until the drug susceptible bacteria overpowers the less
fit drug-resistant bacteria. This idea is wrong.” Essentially,
powerful new TB drugs requiring a shorter treatment period
are needed to effectively treat and control TB, and to keep
MDR-TB from gaining increased fitness.
The project to track TB transmission in San Francisco
is still an ongoing effort. The project provides information
not only for the study of drug susceptible TB, but also for
drug resistant MDR-TB. Dr. Gagneux explains that “tracking
the genotypes of ongoing transmission helps TB control by
narrowing the focus to target stains that are spreading and
causing outbreaks.”
Confronting TB is a major worldwide health issue that
must continue to be addressed in the coming years and
decades. Though the task is difficult and daunting, Gagneux’s
study and others can point TB control in the right direction
and help make TB truly a disease of the past. S
KATHLEEN JIA is a freshman thinking about a Philosophy-Religious
Studies joint major. She enjoys reading, listening to music, star-gaz-
ing, chatting with her friends, and eating chocolate.
To Learn More:
Read the Science article “The Competitive Cost of Antibiotic
Resistance in Mycobacterium tuberculosis”.
Read the Stanford Daily article“Drug-resistant strains of tuberculosis
are more virulent than experts assumed, study finds” by Mark
Shwartz.
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