fThe novel ATP synthase inhibitor bedaquiline recently received accelerated approval for treatment of multidrug-resistant tuberculosis and is currently being studied as a component of novel treatment-shortening regimens for drug-susceptible and multidrug-resistant tuberculosis. In a limited number of bedaquiline-treated patients reported to date, >4-fold upward shifts in bedaquiline MIC during treatment have been attributed to non-target-based mutations in Rv0678 that putatively increase bedaquiline efflux through the MmpS5-MmpL5 pump. These mutations also confer low-level clofazimine resistance, presumably by a similar mechanism. Here, we describe a new non-target-based determinant of low-level bedaquiline and clofazimine cross-resistance in Mycobacterium tuberculosis: loss-of-function mutations in pepQ (Rv2535c), which corresponds to a putative Xaa-Pro aminopeptidase. pepQ mutants were selected in mice by treatment with clinically relevant doses of bedaquiline, with or without clofazimine, and were shown to have bedaquiline and clofazimine MICs 4 times higher than those for the parental H37Rv strain. Coincubation with efflux inhibitors verapamil and reserpine lowered bedaquiline MICs against both mutant and parent strains to a level below the MIC against H37Rv in the absence of efflux pump inhibitors. However, quantitative PCR (qPCR) revealed no significant differences in expression of Rv0678, mmpS5, or mmpL5 between mutant and parent strains. Complementation of a pepQ mutant with the wild-type gene restored susceptibility, indicating that loss of PepQ function is sufficient for reduced susceptibility both in vitro and in mice. Although the mechanism by which mutations in pepQ confer bedaquiline and clofazimine cross-resistance remains unclear, these results may have clinical implications and warrant further evaluation of clinical isolates with reduced susceptibility to either drug for mutations in this gene.
Multidrug-resistant tuberculosis (MDR-TB) is a major threat to global control of tuberculosis (TB). When multidrug resistance is not diagnosed, patients respond poorly to standardized first-line regimens and additional resistance may develop. When MDR-TB is diagnosed, current second-line regimens require prolonged treatment durations and are less effective, more toxic, and far more expensive than first-line therapy (1).The diarylquinoline drug bedaquiline (B) received accelerated approval from the U.S. Food and Drug Administration as part of combination therapy for MDR-TB when other alternatives are not available (2). It is now being studied as a component of novel short-course regimens for MDR as well as drug-susceptible TB (ClinicalTrials.gov identifiers NCT02333799, NCT02193776, NCT02589782, NCT02409290, and NCT02454205 [https://clinicaltrials.gov/]). For new drugs such as bedaquiline, it is essential to define and catalog the mechanisms conferring bacterial resistance in order to design appropriate diagnostic tests (including rapid molecular tests), to better manage the treatment of patients who fail ...