Proportion of mice with positive culture of lung 3 months after treatment completion (relapse).^*

<p>*Lung CFU count at start of treatment (D0): 7.1 log10 CFU.</p><p>Definition of abbreviations: J = TMC 207, R = Rifampin, M = Moxifloxacin, H = Isoniazid, Z = Pyrazinamide, A = amikacin, Et = ethionamide.</p>a<p>significantly more relapses than RHZ (p<0.05).</p>b<p>not significantly different from RHZ (p>0.05).</p

Experiment Design.

<p>Definition of abbreviations: J = TMC 207, R = Rifampin, M = Moxifloxacin, H = Isoniazid, Z = Pyrazinamide, A = amikacin, Et = ethionamide.</p><p>Mice were infected intravenously with 1.1×10⁶ of <i>M. tuberculosis</i> H37Rv.</p><p>Day -18: the day after infection, Day 0: start of treatment.</p><p>*Mice kept untreated for mortality assessment.</p><p>All drugs were given 5 times per week at the following doses: J, 25 mg/kg; R, 10 mg/kg; M, 100 mg/kg; H, 25 mg/kg; Z, 150 mg/kg; A, 150 mg/kg; Et, 50 mg/kg.</p

Multiplication of <i>M</i>. <i>leprae</i> organisms in mice treated by BDQ administered orally and the benefit of the combination of CFZ and BDQ (each mouse footpad is taken as a data point and the dotted line indicates the threshold of detection of <i>M</i>. <i>leprae</i>).

Multiplication of M. leprae organisms in mice treated by BDQ administered orally and the benefit of the combination of CFZ and BDQ (each mouse footpad is taken as a data point and the dotted line indicates the threshold of detection of M. leprae).</p

Bactericidal activity against <i>M</i>. <i>leprae</i> THAI53 of bedaquiline administered orally and bedaquiline long-acting measured in Swiss mice by the proportional bactericidal method.

Bactericidal activity against M. leprae THAI53 of bedaquiline administered orally and bedaquiline long-acting measured in Swiss mice by the proportional bactericidal method.</p

Multiplication of <i>M</i>. <i>leprae</i> organisms in nude mice to determine minimal effective dose of BDQ administered orally active against <i>M</i>. <i>leprae</i> and the benefit of the combination of CFZ and BDQ.

Multiplication of M. leprae organisms in nude mice to determine minimal effective dose of BDQ administered orally active against M. leprae and the benefit of the combination of CFZ and BDQ.</p

Acquired Resistance of <i>Mycobacterium tuberculosis</i> to Bedaquiline

<div><p>Bedaquiline (BDQ), an ATP synthase inhibitor, is the first drug to be approved for treatment of multi-drug resistant tuberculosis in decades. <i>In vitro</i> resistance to BDQ was previously shown to be due to target-based mutations. Here we report that non-target based resistance to BDQ, and cross-resistance to clofazimine (CFZ), is due to mutations in Rv0678, a transcriptional repressor of the genes encoding the MmpS5-MmpL5 efflux pump. Efflux-based resistance was identified in paired isolates from patients treated with BDQ, as well as in mice, in which it was confirmed to decrease bactericidal efficacy. The efflux inhibitors verapamil and reserpine decreased the minimum inhibitory concentrations of BDQ and CFZ <i>in vitro</i>, but verapamil failed to increase the bactericidal effect of BDQ in mice and was unable to reverse efflux-based resistance <i>in vivo</i>. Cross-resistance between BDQ and CFZ may have important clinical implications.</p></div

Mutations in <i>Rv0678</i> gene of <i>M. tuberculosis</i> BDQ resistant strains.

<p><b>A.</b> PCR fragment amplified for sequencing and mapping of mutations in <i>Rv0678</i> gene of BDQ resistant strains in (<b>B</b>) H37Rv-derived mutants and (<b>C</b>) EH 3.0-derived mutants. Codons START and STOP of <i>Rv0678</i> gene are underlined. The nucleotide positions are indicated on top of each mutation. Mutations are bold and colored: missense mutations are indicated in green, insertions are highlighted in red, and the 1.3 Kb insertion sequence IS<i>6110</i> is colored in blue. The direct repeats of IS<i>6110</i> are indicated in italics.</p

Mutations in <i>Rv0678</i> gene and MICs of BDQ of resistant preclinical strains.

<p>The MICs of BDQ-R preclinical strains derived from either the drug susceptible H37Rv or the MDR EH3.0 parent strains are shown. Fold-changes between brackets represent the difference between resistant and wild-type MICs. <b>wt</b>: wild-type; <b>Ins</b>: insertion; <b>nt</b>: nucleotide<b>; BDQ</b>: bedaquiline; <b>BDQ-R</b>: bedaquiline-resistant.</p

Translational effect of non-target based resistance to BDQ in mice and inability of verapamil to reverse it.

<p>Log kill values of wild type H37Rv and <i>Rv0678</i> mutants in mice treated with BDQ at 6.25 or 50 mg/kg (5x/week), in the presence (25 V) or absence (0 V) of 25 mg/kg verapamil for 4 weeks. Values represent the median log reduction versus baseline CFU for 6 mice.</p

Top 10 upregulated proteins of the BDQ-resistant strains EH3.6 and EH 3.2 compared to EH3.0.

<p>Proteins displaying the highest differential upregulation factors (top 10 proteins) are indicated. The descriptions of the genes were retrieved from TubercuList (<a href="http://tuberculist.epfl.ch/" target="_blank">http://tuberculist.epfl.ch/</a>).</p