Imperfect drug penetration leads to spatial monotherapy and rapid evolution of multidrug resistance

Abstract

Infections with rapidly evolving pathogens are often treated using combinations of drugs with different mechanisms of action. One of the major goal of combination therapy is to reduce the risk of drug resistance emerging during a patient’s treatment. Although this strategy generally has significant benefits over monotherapy, it may also select for multidrug-resistant strains, particularly during long-term treatment for chronic infections. Infections with these strains present an important clinical and public health problem. Complicating this issue, for many antimicrobial treatment regimes, individual drugs have imperfect penetration throughout the body, so there may be regions where only one drug reaches an effective concentration. Here we propose that mismatched drug coverage can greatly speed up the evolution of multidrug resistance by allowing mutations to accumulate in a stepwise fashion. We develop a mathematical model of within-host pathogen evolution under spatially heterogeneous drug coverage and demonstrate that even very small single-drug compartments lead to dramatically higher resistance risk. We find that it is often better to use drug combinations with matched penetration profiles, although there may be a trade-off between preventing eventual treatment failure due to resistance in this way and temporarily reducing pathogen levels systemically. Our results show that drugs with the most extensive distribution are likely to be the most vulnerable to resistance. We conclude that optimal combination treatments should be designed to prevent this spatial effective monotherapy. These results are widely applicable to diverse microbial infections including viruses, bacteria, and parasites.

A spatio-temporal assessment of simian/human immunodeficiency virus (SHIV) evolution reveals a highly dynamic process within the host

“…Previous studies have suggested that HIV-1 drug resistance originates primarily in tissues with low or absent drug concentration (i.e., drug sanctuaries) [2–4]. If this holds true, then efforts should focus on improving drug penetration in these tissues.…”

Insights into the processes that drive the evolution of drug resistance in Mycobacterium tuberculosis

“…Furthermore, using mathematical modelling, Moreno‐Gamez et al. (2015) demonstrated that the imperfect drug penetrance leads to spatial mono‐therapy and thus to a rapid evolution towards MDR. In addition, variations in drug absorption in patients (pharmacokinetic variability) can be also a factor of emergence of MDR TB (Pasipanodya & Gumbo, 2011).…”

The population genetics of drug resistance evolution in natural populations of viral, bacterial and eukaryotic pathogens

“…This is troubling, because part of the rationale behind using multiple drugs at the same time is that it should make it much harder for the pathogen to evolve resistance, as it needs to acquire multiple mutations at the same time. It has been suggested that imperfect drug penetration may explain the evolution of resistance in tuberculosis despite multidrug therapy (Lipsitch & Levin 1998; Moreno-Gamez et al 2015). …”