Drug quality analysis of isometamidium chloride hydrochloride and diminazene diaceturate used for the treatment of African animal trypanosomosis in West Africa.

BACKGROUND: Diminazene diaceturate (DA) and isometamidium chloride hydrochloride (ISM) are with homidium bromide, the main molecules used to treat African Animal Trypanosomosis (AAT). These drugs can be purchased from official suppliers but also from unofficial sources like local food markets or street vendors. The sub-standard quality of some of these trypanocides is jeopardizing the efficacy of treatment of sick livestock, leading thus to economic losses for the low-resource farmers and is contributing to the emergence and spread of drug resistance. The objective of this study was to assess the quality of trypanocidal drugs sold in French speaking countries of West Africa. In total, 308 drug samples including 282 of DA and 26 of ISM were purchased from official and unofficial sources in Benin, Burkina Faso, Côte d'Ivoire, Mali, Niger and Togo. All samples were analysed at LACOMEV (Dakar, Senegal), a reference laboratory of the World Organisation for Animal Health, by galenic inspection and high performance liquid chromatography. RESULTS: The results showed that 51.90% of the samples were non-compliant compared to the standards and were containing lower quantity of the active ingredient compared to the indications on the packaging. The non-compliances ranged from 63.27% in Togo to 32.65% in Burkina Faso (61.82% in Benin, 53.84% in Mali, 50% in Côte d'Ivoire, 47.36% in Niger). The rates of non-compliance were not statistically different (P = 0.572) from official or unofficial suppliers and ranged from 30 to 75% and from 0 to 65% respectively. However, the non-compliance was significantly higher for ISM compared to DA (P = 0.028). CONCLUSIONS: The high non-compliance revealed in this study compromises the efficacy of therapeutic strategies against AAT, and is likely to exacerbate chemoresistance in West Africa. Corrective actions against sub-standard trypanocides urgently need to be taken by policy makers and control authorities.

Resistance to trypanocidal drugs in cattle populations of Zambezia Province, Mozambique.

African animal trypanosomosis is a debilitating tsetse-transmitted parasitic disease of sub-Saharan Africa. Therapeutic and prophylactic drugs were introduced more than 50 years ago, and drug resistance is increasingly reported. In a cross-sectional study, 467 cattle were microscopically screened for trypanosomes. Samples were collected in May-July 2014 from five villages (Botao, Mungama, Zalala-Electrosul, Zalala-Madal, and Namitangurine) in Nicoadala district, Zambezia province. To evaluate treatment efficacy, trypanosome-positive animals in each village were randomly assigned to two groups, one treated with 0.5 mg/kg b.w. isometamidium (Inomidium®), the second with 3.5 mg/kg b.w. diminazene (Inomazene®). Cattle were microscopically monitored at days 0, 14, and 28 post-treatment. At day 28, trypanocides were swapped to investigate single or multiple resistance. Microscopically negative samples from the monitoring days were tested using 18S-PCR-RFLP. 22.9% (107/467) was found positive on day 0. On day 14, nine animals in Botao and seven in Mungama were positive. On day 28, in Botao, four animals from the diminazene group and four from the isometamidium group were positive. In Mungama, four animals from the diminazene group were positive on day 28. On day 42, six animals (9%) in Botao and two (9.5%) in Mungama remained positive after drug swap. No relapses occurred in Namitangurine. The 18S-PCR-RFLP consistently detected more positive than microscopy: indeed, positives reached 12, 13, and 8 in Botao and 9, 7, and 4 in Mungama, at days 14, 28, and 42, respectively. Single- and multi-drug resistance in Nicoadala district, Zambezia province, is thus here confirmed. This should be considered when choosing control options.

A systematic review and meta-analysis of trypanosome prevalence in tsetse flies.

BACKGROUND: The optimisation of trypanosomosis control programs warrants a good knowledge of the main vector of animal and human trypanosomes in sub-Saharan Africa, the tsetse fly. An important aspect of the tsetse fly population is its trypanosome infection prevalence, as it determines the intensity of the transmission of the parasite by the vector. We therefore conducted a systematic review of published studies documenting trypanosome infection prevalence from field surveys or from laboratory experiments under controlled conditions. Publications were screened in the Web of Science, PubMed and Google Scholar databases. Using the four-stage (identification, screening, eligibility and inclusion) process in the PRISMA statement the initial screened total of 605 studies were reduced to 72 studies. The microscopic examination of dissected flies (dissection method) remains the most used method to detect trypanosomes and thus constituted the main focus of this analysis. Meta-regression was performed to identify factors responsible for high trypanosome prevalence in the vectors and a random effects meta-analysis was used to report the sensitivity of molecular and serological tests using the dissection method as gold standard. RESULTS: The overall pooled prevalence was 10.3% (95% confidence interval [CI] = 8.1%, 12.4%) and 31.0% (95% CI = 20.0%, 42.0%) for the field survey and laboratory experiment data respectively. The country and the year of publication were found to be significantly factors associated with the prevalence of trypanosome infection in tsetse flies. The alternative diagnostic tools applied to dissection positive samples were characterised by low sensitivity, and no information on the specificity was available at all. CONCLUSION: Both temporal and spatial variation in trypanosome infection prevalence of field collected tsetse flies exists, but further investigation on real risk factors is needed how this variation can be explained. Improving the sensitivity and determining the specificity of these alternative diagnostic tools should be a priority and will allow to estimate the prevalence of trypanosome infection in tsetse flies in high-throughput.

Evaluation of the relative roles of the Tabanidae and Glossinidae in the transmission of trypanosomosis in drug resistance hotspots in Mozambique.

BACKGROUND: Tsetse flies (Diptera: Glossinidae) and tabanids (Diptera: Tabanidae) are haematophagous insects of medical and veterinary importance due to their respective role in the biological and mechanical transmission of trypanosomes. Few studies on the distribution and relative abundance of both families have been conducted in Mozambique since the country's independence. Despite Nicoadala, Mozambique, being a multiple trypanocidal drug resistance hotspot no information regarding the distribution, seasonality or infection rates of fly-vectors are available. This is, however, crucial to understanding the epidemiology of trypanosomosis and to refine vector management. METHODS: For 365 days, 55 traps (20 NGU traps, 20 horizontal traps and 15 Epsilon traps) were deployed in three grazing areas of Nicoadala District: Namitangurine (25 traps); Zalala (15 traps); and Botao (15 traps). Flies were collected weekly and preserved in 70% ethanol. Identification using morphological keys was followed by molecular confirmation using cytochrome c oxidase subunit 1 gene. Trap efficiency, species distribution and seasonal abundance were also assessed. To determine trypanosome infection rates, DNA was extracted from the captured flies, and submitted to 18S PCR-RFLP screening for the detection of Trypanosoma. RESULTS: In total, 4379 tabanids (of 10 species) and 24 tsetse flies (of 3 species), were caught. NGU traps were more effective in capturing both the Tabanidae and Glossinidae. Higher abundance and species diversity were observed in Namitangurine followed by Zalala and Botao. Tabanid abundance was approximately double during the rainy season compared to the dry season. Trypanosoma congolense and T. theileri were detected in the flies with overall infection rates of 75% for tsetse flies and 13% for tabanids. Atylotus agrestis had the highest infection rate of the tabanid species. The only pathogenic trypanosome detected was T. congolense. CONCLUSIONS: Despite the low numbers of tsetse flies captured, it can be assumed that they are still the cyclical vectors of trypanosomosis in the area. However, the high numbers of tabanids captured, associated to their demonstrated capacity of transmitting trypanosomes mechanically, suggest an important role in the epidemiology of trypanosomosis in the Nicoadala district. These results on the composition of tsetse and tabanid populations as well as the observed infection rates, should be considered when defining strategies to control the disease.

Five-fold increase in Trypanosoma congolense isolates resistant to diminazene aceturate over a seven-year period in Eastern Zambia.

Two groups of Trypanosoma congolense isolates collected from cattle in 1996 (n=39) and 2003 (n=38) in the Eastern Province of Zambia were analyzed by BclI-PCR-RFLP to assess the evolution of diminazene aceturate (DA) resistance over a period of seven years. The results show a significant increase of DA resistance in this relatively short period of time. In 1996, among the 39 isolates, 61.5% were found sensitive, 12.8% resistant and 25.7% had a mixed BclI-PCR-RFLP profile. In 2004, among the 38 isolates, 10.5% were found sensitive, 63.2% were resistant and 26.3% showed a mixed BclI-PCR-RFLP profile. In vivo tests in mice showed that isolates with a sensitive or mixed RFLP profile were sensitive to DA whereas isolates with a resistant RFLP profile were resistant. Since there are no indications that the drug pressure has increased between 1996 and 2003, it is suggested that genetic exchange of resistance genes might explain the increased frequency of resistance to DA.

How rational drug use reduces trypanosome infections in cattle in chemo-resistance hot-spot villages of northern Togo.

The study assessed an integrated trypanosomosis control strategy in drug-resistant hotspot villages of northern Togo. This strategy comprised (i) rational trypanocidal drug use in symptomatic cattle, (ii) vectors and ticks control by targeted bi-monthly insecticidal spraying of the lower body parts of cattle and (iii) strategic deworming with Albendazole in the beginning and the end of the rainy season. The program was implemented between June 2014 and October 2015 in four villages in northern Togo, which had been previously identified as drug resistant hotspots for diminazene diaceturate (DA) and isometamidium chloride (ISM). The integrated control strategy was implemented in eight cattle herds at risk of the disease from two villages. Twelve herds from two other villages served as controls where trypanosomosis management and deworming remained under control of the farmers. Trypanocidal drug use during the study period was recorded by the intervention team based on the farmers' reports and own observations. Cattle herds were followed-up for trypanosomosis symptoms which were recorded at 3 to 4-month intervals, while extensive trypanosome diagnostics and recording of the packed cell volume were done before and after the intervention. Intervention herds had a significantly lower risk of trypanosome infection with a risk ratio of 0.18 (95% CI: 0.04, 0.91; p = 0.03), but no significant effect on mean packed cell volume was observed. However, trypanocidal treatments per animal per year were lower in intervention herds compared to control herds (0.3 vs 5 for DA and 0.8 vs 2 for ISM). This study demonstrates that the implementation of an integrated best-bet strategy leads to a reduced trypanosome prevalence under lowered trypanocidal use.

Molecular tools for the rapid detection of drug resistance in animal trypanosomes.

There are currently 17 African countries in which animal trypanocidal drug resistance has been reported. Large-scale surveys were carried out in only ten of them. The lack of baseline information is mainly due to the fact that the methods currently available for the detection of drug resistance are laborious, expensive and time consuming. In this review the mechanisms involved in resistance to isometamidium and diminazene will be discussed, together with some new molecular detection tools that have been developed recently enabling faster diagnosis of drug resistance than conventional laboratory or field tests.

Comparative evaluation of the nested ITS PCR against the 18S PCR-RFLP in a survey of bovine trypanosomiasis in Kwale County, Kenya.

We compared the nested internal transcribed spacer (ITS) PCR and the 18S PCR-RFLP (restriction-fragment length polymorphism) pan-trypanosome assays in a cross-sectional survey of bovine trypanosomiasis in 358 cattle in Kwale County, Kenya. The prevalence of trypanosomiasis as determined by the nested ITS PCR was 19.6% (70/358) and by 18S PCR-RFLP was 16.8% (60/358). Of the pathogenic trypanosomes detected, the prevalence of Trypanosoma congolense and Trypanosoma vivax was greater than that of Trypanosoma simiae The nested ITS PCR detected 83 parasite events, whereas the 18S PCR-RFLP detected 64; however, overall frequencies of infections and the parasite events detected did not differ between the assays (χ(2) = 0.8, df = 1, p > 0.05 and χ(2) = 2.5, df = 1, p > 0.05, respectively). The kappa statistic (0.8) showed good agreement between the tests. The nested ITS PCR and the 18S PCR-RFLP had comparable sensitivity, although the nested ITS PCR was better at detecting mixed infections (χ(2) = 5.4, df = 1, p < 0.05).

Spatial distribution of Glossina sp. and Trypanosoma sp. in south-western Ethiopia.

BACKGROUND: Accurate information on the distribution of the tsetse fly is of paramount importance to better control animal trypanosomosis. Entomological and parasitological surveys were conducted in the tsetse belt of south-western Ethiopia to describe the prevalence of trypanosomosis (PoT), the abundance of tsetse flies (AT) and to evaluate the association with potential risk factors. METHODS: The study was conducted between 2009 and 2012. The parasitological survey data were analysed by a random effects logistic regression model, whereas the entomological survey data were analysed by a Poisson regression model. The percentage of animals with trypanosomosis was regressed on the tsetse fly count using a random effects logistic regression model. RESULTS: The following six risk factors were evaluated for PoT (i) altitude: significant and inverse correlation with trypanosomosis, (ii) annual variation of PoT: no significant difference between years, (iii) regional state: compared to Benishangul-Gumuz (18.0%), the three remaining regional states showed significantly lower PoT, (iv) river system: the PoT differed significantly between the river systems, (iv) sex: male animals (11.0%) were more affected than females (9.0%), and finally (vi) age at sampling: no difference between the considered classes. Observed trypanosome species were T. congolense (76.0%), T. vivax (18.1%), T. b. brucei (3.6%), and mixed T. congolense/vivax (2.4%). The first four risk factors listed above were also evaluated for AT, and all have a significant effect on AT. In the multivariable model only altitude was retained with AT decreasing with increasing altitude. Four different Glossina species were identified i.e. G. tachinoides (52.0%), G. pallidipes (26.0%), G.morsitans submorsitans (15.0%) and G. fuscipes fuscipes (7.0 %). Significant differences in catches/trap/day between districts were observed for each species. No association could be found between the tsetse fly counts and trypanosomosis prevalence. CONCLUSIONS: Trypanosomosis remains a constraint to livestock production in south-western Ethiopia. Four Glossina and three Trypanosoma species were observed. Altitude had a significant impact on AT and PoT. PoT is not associated with AT, which could be explained by the importance of mechanical transmission. This needs to be investigated further as it might jeopardize control strategies that target the tsetse fly population.

Development and evaluation of an ITS1 "Touchdown" PCR for assessment of drug efficacy against animal African trypanosomosis.

Animal African trypanosomoses (AAT) are caused by flagellated protozoa of the Trypanosoma genus and contribute to considerable losses in animal production in Africa, Latin America and South East Asia. Trypanosoma congolense is considered the economically most important species. Drug resistant T. congolense strains present a threat to the control of AAT and have triggered research into discovery of novel trypanocides. In vivo assessment of trypanocidal efficacy relies on monitoring of treated animals with microscopic parasite detection methods. Since these methods have poor sensitivity, follow-up for up to 100 days after treatment is recommended to increase the chance of detecting recurrent parasitaemia waves. Molecular techniques are more amendable to high throughput processing and are generally more sensitive than microscopic detection, thus bearing the potential of shortening the 100-day follow up period. The study presents a "Touchdown" PCR targeting the internal transcribed spacer 1 of the ribosomal DNA (ITS1 TD PCR) that enables detection and discrimination of different Trypanosoma taxa in a single run due to variations in PCR product sizes. The assay achieves analytical sensitivity of 10 parasites per ml of blood for detection of T. congolense savannah type and T. brucei, and 100 parasites per ml of blood for detection of T. vivax in infected mouse blood. The ITS1 TD PCR was evaluated on cattle experimentally infected with T. congolense during an investigational new veterinary trypanocide drug efficacy study. ITS1 TD PCR demonstrated comparable performance to microscopy in verifying trypanocide treatment success, in which parasite DNA became undetectable in cured animals within two days post-treatment. ITS1 TD PCR detected parasite recrudescence three days earlier than microscopy and had a higher positivity rate than microscopy (84.85% versus 57.58%) in 66 specimens of relapsing animals collected after treatments. Therefore, ITS1 TD PCR provides a useful tool in assessment of drug efficacy against T. congolense infection in cattle. As the assay bears the potential for detection of mixed infections, it may be applicable for drug efficacy studies and diagnostic discrimination of T. vivax and T. congolense against other pathogenic trypanosomes, including T. brucei, T. evansi and T. equiperdum.

Functional expression of TcoAT1 reveals it to be a P1-type nucleoside transporter with no capacity for diminazene uptake.

It has long been established that the Trypanosoma brucei TbAT1/P2 aminopurine transporter is involved in the uptake of diamidine and arsenical drugs including pentamidine, diminazene aceturate and melarsoprol. Accordingly, it was proposed that the closest Trypanosoma congolense paralogue, TcoAT1, might perform the same function in this parasite, and an apparent correlation between a Single Nucleotide Polymorphism (SNP) in that gene and diminazene tolerance was reported for the strains examined. Here, we report the functional cloning and expression of TcoAT1 and show that in fact it is the syntenic homologue of another T. brucei gene of the same Equilibrative Nucleoside Transporter (ENT) family: TbNT10. The T. congolense genome does not seem to contain a syntenic equivalent to TbAT1. Two TcoAT1 alleles, differentiated by three independent SNPs, were expressed in the T. brucei clone B48, a TbAT1-null strain that further lacks the High Affinity Pentamidine Transporter (HAPT1); TbAT1 was also expressed as a control. The TbAT1 and TcoAT1 transporters were functional and increased sensitivity to cytotoxic nucleoside analogues. However, only TbAT1 increased sensitivity to diamidines and to cymelarsan. Uptake of [(3)H]-diminazene was detectable only in the B48 cells expressing TbAT1 but not TcoAT1, whereas uptake of [(3)H]-inosine was increased by both TcoAT1 alleles but not by TbAT1. Uptake of [(3)H]-adenosine was increased by all three ENT genes. We conclude that TcoAT1 is a P1-type purine nucleoside transporter and the syntenic equivalent to the previously characterised TbNT10; it does not mediate diminazene uptake and is therefore unlikely to play a role in diminazene resistance in T. congolense.

Widespread occurrence of Trypanosoma vivax in bovines of tsetse- as well as non-tsetse-infested regions of Ethiopia: a reason for concern?

A cross-sectional study was undertaken to assess the prevalence of bovine trypanosomosis in some tsetse-infested and tsetse-free areas of Ethiopia. From August 2010 till April 2011, a total of 1524 animals were parasitologically examined and compared by the haematocrit centrifugation technique (Woo test) and polymerase chain reaction (ITS-1 PCR). The ITS-1 PCR was more sensitive and more accurate in species identification than the Woo test. In ITS-1 PCR, an overall trypanosome prevalence of 31.0% was observed that is significantly (P<0.001) higher than in the Woo test (5.3%). Trypanosoma vivax was the predominant taxon (24.9%), followed by T. theileri (6.0%), T. congolense (2.9%) and Trypanozoon (1.6%). Mixed infections were quite common (14% of all infections). The overall prevalence of trypanosome infections in tsetse area (32.4%) was not different from non-tsetse area (30.5%) neither were the prevalences of T. vivax in both areas (respectively 22.6% and 25.7%). With these high prevalences, bovine trypanosomosis continues to hinder animal production and productivity in Ethiopia, both in tsetse-infested and non-infested parts of the country. Attempts to control African trypanosomosis should also pay attention to mechanically transmitted pathogenic trypanosomes and should adopt the most advanced molecular tests for species identification.

Is trypanocidal drug resistance a threat for livestock health and production in endemic areas? Food for thoughts from Sahelian goats infected by Trypanosoma vivax in Bobo Dioulasso (Burkina Faso).

Trypanocidal drug resistance is unanimously recognized as a threat for livestock production in regions where the prevalence of trypanosomosis is high. To assess the impact of the disease and the effect of drug resistance on the health of small ruminants, twelve Trypanosoma vivax isolates collected in 6 villages in the vicinity of Bobo Dioulasso (Burkina Faso) were injected into 12 groups of 5 Sahelian goats, two being treated with 3.5mg/kg body weight diminazene aceturate (DA), two with 0.5mg/kg body weight isometamidium chloride (ISM) and one left untreated as control. A monitoring was performed every 5 days for 100 days to evaluate the parasitaemia by buffy coat examination, the hematocrit and the body weight. Among the 12 groups, 6 were additionally monitored using a trypanosome specific 18S-PCR-RFLP every 5 days from day 30 to day 100 to verify the complete clearance of the parasites from the blood of the hosts. In six groups of goats, trypanosomes disappeared completely after treatment, five groups showed relapses in at least one goat treated with ISM and one group showed relapses in one goat treated with DA and one with ISM. For the 6 groups that were screened both using microscopic examination and trypanosome specific 18S-PCR-RFLP, the following results were observed: for the groups treated with DA, no relapses by microscopic examination and 83.3% (10/12) using the 18S-PCR-RFLP. For the groups treated with ISM, 25% (3/12) relapses by microscopic examination and 83.3% with the 18S-PCR-RFLP (10/12). The evolution of the PCV and the weight during the observation period from relapsing (either by microscopical examination or by 18S-PCR-RFLP diagnosis) and non relapsing animals were compared. The relative average PCV in goats that relapsed microscopically, decreased significantly more than in non-relapsing goats. This difference was not significant when relapses were detected using the trypanosome specific 18S-PCR-RFLP. This indicates that only the animals with the highest parasitaemia suffered from the infection. Relapses after treatment where the host controls the parasitaemia to a level below the sensitivity of the microscopical examination do not affect body weight nor PCV.

High prevalence of drug resistance in animal trypanosomes without a history of drug exposure.

BACKGROUND: Trypanosomosis caused by Trypanosoma congolense is a major constraint to animal health in sub-Saharan Africa. Unfortunately, the treatment of the disease is impaired by the spread of drug resistance. Resistance to diminazene aceturate (DA) in T. congolense is linked to a mutation modifying the functioning of a P2-type purine-transporter responsible for the uptake of the drug. Our objective was to verify if the mutation was linked or not to drug pressure. METHODOLOGY/PRINCIPAL FINDINGS: Thirty-four T. congolense isolates sampled from tsetse or wildlife were screened for the DA-resistance linked mutation using DpnII-PCR-RFLP. The results showed 1 sensitive, 12 resistant and 21 mixed DpnII-PCR-RFLP profiles. This suggests that the mutation is present on at least one allele of each of the 33 isolates. For twelve of the isolates, a standard screening method in mice was used by (i) microscopic examination, (ii) trypanosome-specific 18S-PCR after 2 months of observation and (iii) weekly trypanosome-specific 18S-PCR for 8 weeks. The results showed that all mice remained microscopically trypanosome-positive after treatment with 5 mg/kg DA. With 10 and 20 mg/kg, 8.3% (n = 72) and 0% (n = 72) of the mice became parasitologically positive after treatment. However, in these latter groups the trypanosome-specific 18S-PCR indicated a higher degree of trypanosome-positivity, i.e., with a unique test, 51.4% (n = 72) and 38.9% (n = 72) and with the weekly tests 79.2% (n = 24) and 66.7% (n = 24) for 10 and 20 mg/kg respectively. CONCLUSION/SIGNIFICANCE: The widespread presence of the DA-resistance linked mutation in T. congolense isolated from wildlife suggests that this mutation is favourable to parasite survival and/or its dissemination in the host population independent from the presence of drug. After treatment with DA, those T. congolense isolates cause persisting low parasitaemias even after complete elimination of the drug and with little impact on the host's health.

Chemosensitization of Trypanosoma congolense strains resistant to isometamidium chloride by tetracyclines and enrofloxacin.

BACKGROUND: Because of the development of resistance in trypanosomes to trypanocidal drugs, the livelihood of millions of livestock keepers in sub-Saharan Africa is threatened now more than ever. The existing compounds have become virtually useless and pharmaceutical companies are not keen on investing in the development of new trypanocides. We may have found a breakthrough in the treatment of resistant trypanosomal infections, through the combination of the trypanocide isometamidium chloride (ISM) with two affordable veterinary antibiotics. METHODOLOGY/PRINCIPAL FINDINGS: In a first experiment, groups of mice were inoculated with Trypanosoma congolense strains resistant to ISM and either left untreated or treated with (i) tetracycline, (ii) ISM or (iii) the combination of the antibiotic and the trypanocide. Survival analysis showed that there was a significant effect of treatment and resistance to treatment on the survival time. The groups treated with ISM (with or without antibiotic) survived significantly longer than the groups that were not treated with ISM (P<0.01). The group treated with the combination trypanocide/antibiotic survived significantly longer than the group treated with ISM (P<0.01). In a second experiment, groups of cattle were inoculated with the same resistant trypanosome strain and treated with (i) ISM, (ii) ISM associated with oxytetracycline or (iii) ISM associated with enrofloxacine. All animals treated with ISM became parasitaemic. In the groups treated with ISM-oxytetracycline and ISM-enrofloxacine, 50% of the animals were cured. Animals from the groups treated with a combination trypanocide/antibiotic presented a significantly longer prepatent period than animals treated with ISM (p<0.001). The impact of the disease on the haematocrit was low in all ISM treated groups. Yet, it was lower in the groups treated with the combination trypanocide/antibiotic (p<0.01). CONCLUSIONS/SIGNIFICANCE: After optimization of the administration protocol, this new therapeutic combination could constitute a promising treatment for livestock infected with drug resistant T. congolense.

Drugs and drug resistance in African trypanosomiasis.

Despite the many decades of use of most of the current trypanocides, we know little of their mode of action. This may in part be because most of these will act on multiple targets once inside the cell, and they derive their selective action on the parasite from selective accumulation by the pathogen. Loss of this capacity for drug uptake by the trypanosome would thus be a major cause for drug resistance. We here discuss the use of current drugs against human and veterinary African trypanosomiasis, the prevalence, causes and mechanisms of drug resistance and new developments in trypanosomiasis therapy such as the introduction of nifurtimox and DB289.