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

Stefany Moreno-Gamez, Alison L. Hill, Daniel I. S. Rosenbloom, Dmitri A. Petrov, Martin A. Nowak, Pleuni S. Pennings*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

64 Citations (Scopus)

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.

Original languageEnglish
Pages (from-to)E2874-E2883
Number of pages10
JournalProceedings of the National Academy of Science of the United States of America
Volume112
Issue number22
DOIs
Publication statusPublished - 2-Jun-2015

Keywords

  • drug resistance
  • combination therapy
  • drug sanctuaries
  • spatial structure
  • pathogen evolution
  • IMMUNODEFICIENCY-VIRUS TYPE-1
  • HEPATITIS-B-VIRUS
  • STAPHYLOCOCCUS-AUREUS
  • ANTIRETROVIRAL THERAPY
  • ANTIBIOTIC-RESISTANCE
  • CEREBROSPINAL-FLUID
  • HIV-1 INFECTION
  • COMBINATION THERAPY
  • SANCTUARY SITES
  • PRE-EXISTENCE

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