Journal of Antimicrobial Chemotherapy (2009) 64, 428 435 doi:10.

1093/jac/dkp174 Advance Access publication 19 May 2009

Comparative in vitro activities of the new quinolone nemonoxacin (TG-873870), gemioxacin and other quinolones against clinical isolates of Mycobacterium tuberculosis
Che-Kim Tan1, Chih-Cheng Lai2, Chun-Hsing Liao3, Chien-Hong Chou4, Hsiao-Leng Hsu5, Yu-Tsung Huang5,6 and Po-Ren Hsueh5,6* Department of Intensive Care Medicine, Chi-Mei Medical Center, Tainan, Taiwan; 2Department of Internal Medicine, Yi-Min Hospital, Taipei, Taiwan; 3Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei County, Taiwan; 4Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan; 5 Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; 6Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
Keywords: M. tuberculosis, TB, MDR-TB *Corresponding author. Tel: 886-2-23123456, ext. 65355; Fax: 886-2-23224263; E-mail: hsporen@ntu.edu.tw Sir, The emergence of resistance of Mycobacterium tuberculosis to uoroquinolones in patients with newly diagnosed infection has been a concern, especially in patients who have prior exposure to uoroquinolones.1 Furthermore, the usage of uoroquinolones in community-acquired infection has been reported to delay the diagnosis of tuberculosis (TB).2,3 The development of a new quinolone that retains the antibacterial activity spectrum of classic uoroquinolones but with a relatively low activity against M. tuberculosis might have a role to play in removing the concern of potentially delaying the diagnosis of TB. Nemonoxacin (TG-873870) is a non-uorinated quinolone that is currently being developed in oral and intravenous formulations. This agent has good in vitro activities against major pathogens from respiratory tract and skin infections, including penicillin-resistant Streptococcus pneumoniae and methicillinresistant Staphylococcus aureus. This agent differs from uoroquinolones in that it lacks the uorine in the C6 position; the uorine atom at C6 improves cell penetration and gyrase afnity.4 Nemonoxacin acts by inhibiting bacterial DNA gyrase and topoisomerase IV and retains potent broad-spectrum activities against Gram-positive and -negative bacteria.5 As there is no evidence of the topoisomerase IV gene in the genome of M. tuberculosis, gyrase appears to be the sole target for quinolones in M. tuberculosis.4,6 The purpose of this study was to compare the susceptibilities of M. tuberculosis isolates to nemonoxacin and classic uoroquinolones (ciprooxacin, levooxacin, moxioxacin and gemioxacin).
1

In total, 109 non-duplicate and consecutive TB isolates, recovered from various clinical specimens, were collected from 2000 to 2007 at the National Taiwan University Hospital (NTUH). Susceptibility to rst-line anti-TB drugs, including isoniazid (0.2 and 1.0 mg/L), rifampicin (1 mg/L) and ethambutol (5 mg/L), and second-line anti-TB drugs, including streptomycin (2 and 10 mg/L), rifabutin (0.5 mg/L), ooxacin (2 mg/L), ethionamide (5 mg/L) and para-aminosalicylic acid (2 mg/L), was determined in the Mycobacteriology Laboratory of NTUH using modied, proportional, disc elution methods. A M. tuberculosis suspension was inoculated onto Middlebrook 7H10 agar (BBL Microbiology Systems, Cockeysville, MD, USA) that contained anti-TB drugs at respective concentrations. The tested isolate was considered resistant if the proportion of the tested isolate was .1% of the control population. A multidrugresistant (MDR)-TB isolate was dened as being resistant to isoniazid (0.2 mg/L) and rifampicin (1 mg/L). MICs of ve quinolones for 66 MDR-TB isolates and 43 non-MDR-TB isolates collected from 2000 to 2007 were determined using the agar dilution method.7 Concentrations in the range 0.03 32 mg/L were tested. The MIC of each isolate/drug pair was the lowest concentration of the agent that inhibited .99% of the growth of colonies for the drug-free control. Resistance was presumptively dened as follows: .2 mg/L for ciprooxacin and levooxacin; and .0.5 mg/L for moxioxacin.8 For gemioxacin and nemonoxacin, no MIC interpretive criteria were available. All of the 43 non-MDR-TB isolates were susceptible to ethambutol, rifabutin, ethionamide, para-aminosalicylic acid and ooxacin; 30.2% of the non-MDR-TB isolates were resistant to streptomycin. The rates of resistance to ethambutol, streptomycin, rifabutin, ethionamide, para-aminosalicylic acid and ooxacin for MDR-TB were 66.7%, 40.9%, 56.1%, 12.1%, 12.1% and 15.5%, respectively. The MIC distribution and MICs at which 50% (MIC50) and 90% (MIC90) of the isolates were inhibited for the 66 MDR-TB and 43 non-MDR-TB isolates are shown in Table 1. The MICs of the tested quinolones for both non-MDR-TB and MDR-TB isolates were in the order of moxioxacin , levooxacin , ciprooxacin , nemonoxacin gemioxacin. For non-MDR-TB isolates, the rates of susceptibility to levooxacin, ciprooxacin and moxioxacin were 100%, 95.3% and 86%, respectively. For MDR-TB isolates, the rates of susceptibility to levooxacin, ciprooxacin and moxioxacin were 62.1%, 50% and 60.6%, respectively. Notably, the MIC90s of the ve quinolones for MDR-TB isolates were at least 4 times higher than the MIC90s for non-MDR-TB isolates. Among the ve quinolones tested, levooxacin and moxioxacin had the lowest MICs for M. tuberculosis; in most cases, the levooxacin and moxioxacin MICs were at least 16 times lower than those of nemonoxacin. The MIC90s of nemonoxacin and gemioxacin for non-MDR-TB isolates in this study were 16 mg/L. Nine isolates that were resistant to all four classic quinolones (ooxacin, ciprooxacin, moxioxacin and levooxacin) had both nemonoxacin and gemioxacin MICs of .32 mg/L.

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Research letters
Table 1. MIC distribution of nemonoxacin and four uoroquinolones against 66 MDR and 43 non-MDR clinical isolates of M. tuberculosis MIC (mg/L) Drug MDR-TB (n 66) levooxacin moxioxacin ciprooxacin gemioxacin nemonoxacin Non-MDR-TB (n 43) levooxacin moxioxacin ciprooxacin gemioxacin nemonoxacin
a b

,0.03 0.03 0.06 0.12 0.25

0.5

16

32 .32 No. (%) of resistant isolates

0 0 0 0 1 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0 0 1 0 0 0 0 0 0 0

17 34 a 6 0 0 8 22 a 1 0 0

17 a 6 5 0 0 27 a 15 7 0 0

5 5 15 1 1

2 2 6a 0 3

8 7b 5 9 5 0 0 2 10 12

13 b 12 15 8 12 0 0 0 22 a 25 a

4 0 0 0 8b 3 19 a 11 15 a 10 0 0 0 10 b 5b 0 0 0 0 0

0 0 2 18 b 19 b 0 0 0 0 0

25 (37.9%) 26 (39.4%) 33 (50.0%)

8b 0 6b 0 20 a 13 b 0 1 0 1

0 (0.0%) 6 (14.0%) 2 (4.7%)

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MIC50 of each indicated agent. MIC90 of each indicated agent.

Our ndings are consistent with previous reports9,10 and suggest that moxioxacin and levooxacin may be suitable alternative agents, or even candidates for use as new rst-line agents, in patients with non-MDR-TB infections. Among patients with MDR-TB isolates, uoroquinolone susceptibility should be routinely evaluated to cautiously select appropriate antimicrobial agents in Taiwan or other areas with a high uoroquinolone resistance rate. Controversy exists as to whether the usage of quinolones, with good anti-TB activity, in community-acquired pneumonia delays the diagnosis of TB, particularly in areas with a high endemicity of TB.2,3 With their low activity against M. tuberculosis, nemonoxacin and gemioxacin are likely to have the least potential to mask and delay the diagnosis of TB. In conclusion, the high resistance rate of MDR-TB to both rst- and second-line anti-TB agents remains a therapeutic challenge in Taiwan, and more effective TB control interventions and potent anti-TB agents are urgently needed. The higher MICs of nemonoxacin and gemioxacin for non-MDR-TB and MDR-TB isolates indicates the limited role of these two agents in the treatment of TB. The potential role of nemonoxacin and gemioxacin in treating community-acquired pneumonia without masking and delaying the diagnosis of TB requires further study.

References
1. Ginsburg AS, Grosset JH, Bishai WR. Fluoroquinolones, tuberculosis, and resistance. Lancet Infect Dis 2003; 3: 43242. 2. Wang JY, Hsueh PR, Jan IS et al. Empirical treatment with a uoroquinolone delays the treatment for tuberculosis and is associated with a poor prognosis in endemic areas. Thorax 2006; 61: 9038. 3. Dooley KE, Golub J, Goes FS et al. Empiric treatment of community-acquired pneumonia with uoroquinolones, and delays in the treatment of tuberculosis. Clin Infect Dis 2005; 34: 160712. 4. Carta A, Piras S, Palomba M et al. Anti-mycobacterial activity of quinolones. Triazoloquinolones a new class of potent antimycobacterial agents. Anti-Infective Agents Med Chem 2008; 7: 134 47. 5. Chen SJ, Lin L, Chang LW et al. Analysis of antibacterial response of nemonoxacin (TG-873870) against major pathogens from respiratory tract and skin infections. In: Abstracts of the Forty-fth Annual Meeting of IDSA, San Diego, CA, 2007. Abstract 441. 6. Cole ST, Brosch R, Parkhill J et al. Deciphering the biology of Mycobacterium tuberculosis from the complete genome sequence. Nature 1998; 393: 53744 7. National Committee for Clinical Laboratory Standards. Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic Actinomycetes: Approved Standard M24-A. NCCLS, Wayne, PA, USA, 2003. 8. World Health Organization. Policy Guidance on DrugSusceptibility Testing (DST) of Second-Line Antituberculosis Drugs. WHO/HTM/TB/2008.392. Geneva, Switzerland: WHO, 2008. http:// www.who.int/tb/publications/2008/who_htm_tb_2008_392.pdf (15 January 2009, date last accessed). 9. Lai CC, Tan CK, Huang YT et al. Extensively drug-resistant Mycobacterium tuberculosis during a trend of declining drug resistance from 2000 through 2006 at a medical center in Taiwan. Clin Infect Dis 2008; 47: e5763. 10. Ruiz-Serrano MJ, Alcala L, Martnez L et al. In vitro activities of six uoroquinolones against 250 clinical isolates of Mycobacterium tuberculosis susceptible or resistant to rst-line antituberculosis drugs. Antimicrob Agents Chemother 2000; 44: 25678.

Funding
This study was partly supported by the Institute for Biotechnology and Medicine Industry, Taiwan (DOH97 -DC-1501) and TaiGen Biotechnology Co. Ltd, Taipei, Taiwan.

Transparency declarations
None to declare.

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