Pfmdr1 copy number and arteminisin derivatives combination therapy failure in falciparum malaria in Cambodia.

BACKGROUND: The combination of artesunate and mefloquine was introduced as the national first-line treatment for Plasmodium falciparum malaria in Cambodia in 2000. However, recent clinical trials performed at the Thai-Cambodian border have pointed to the declining efficacy of both artesunate-mefloquine and artemether-lumefantrine. Since pfmdr1 modulates susceptibility to mefloquine and artemisinin derivatives, the aim of this study was to assess the link between pfmdr1 copy number, in vitro susceptibility to individual drugs and treatment failure to combination therapy. METHODS: Blood samples were collected from P. falciparum-infected patients enrolled in two in vivo efficacy studies in north-western Cambodia: 135 patients were treated with artemether-lumefantrine (AL group) in Sampovloun in 2002 and 2003, and 140 patients with artesunate-mefloquine (AM group) in Sampovloun and Veal Veng in 2003 and 2004. At enrollment, the in vitro IC50 was tested and the strains were genotyped for pfmdr1 copy number by real-time PCR. RESULTS: The pfmdr1 copy number was analysed for 115 isolates in the AM group, and for 109 isolates in the AL group. Parasites with increased pfmdr1 copy number had significantly reduced in vitro susceptibility to mefloquine, lumefantrine and artesunate. There was no association between pfmdr1 polymorphisms and in vitro susceptibilities. In the patients treated with AM, the mean pfmdr1copy number was lower in subjects with adequate clinical and parasitological response compared to those who experienced late treatment failure (n = 112, p < 0.001). This was not observed in the patients treated with AL (n = 96, p = 0.364). The presence of three or more copies of pfmdr1 were associated with recrudescence in artesunate-mefloquine treated patients (hazard ratio (HR) = 7.80 [95%CI: 2.09-29.10], N = 115), p = 0.002) but not with recrudescence in artemether-lumefantrine treated patients (HR = 1.03 [95%CI: 0.24-4.44], N = 109, p = 0.969). CONCLUSION: This study shows that pfmdr1 copy number is a molecular marker of AM treatment failure in falciparum malaria on the Thai-Cambodian border. However, while it is associated with increased IC50 for lumefantrine, pfmdr1 copy number is not associated with AL treatment failure in the area, suggesting involvement of other molecular mechanisms in AL treatment failures in Cambodia.

Countrywide survey shows very high prevalence of Plasmodium falciparum multilocus resistance genotypes in Cambodia.

Cambodia is located in an area of resistance to multiple antimalarials and has been the first country to implement the systematic use of an artesunate-mefloquine combination as first-line treatment for Plasmodium falciparum malaria. Little is known, however, about the prevalence of resistance mutations within the natural parasite populations, impeding rational drug policy in this context. Using direct sequencing of PCR products, we have analyzed sequence polymorphism of the dihydrofolate reductase-thymidylate synthase, dihydropteroate synthetase, and multidrug resistance 1 genes in a large number of clinical P. falciparum isolates collected in various areas of Cambodia. This highlighted a 100% prevalence of haplotypes with multiple mutations in the target genes of antifolates after more than a decade without use of antifolates for malaria therapy. A high prevalence of mutations in Pfmdr1, including mutations associated with decreased in vitro susceptibility to mefloquine and quinine, was also observed. In addition, novel, low-frequency mutations were detected in Pfmdr1. Our findings show an alarming rate of multilocus resistance genotypes in Cambodia, requiring diligent surveillance and imposing limitations on possible future drug combinations.

Double staining of Plasmodium falciparum nucleic acids with hydroethidine and thiazole orange for cell cycle stage analysis by flow cytometry.

BACKGROUND: Microarray analyses of stage-specific gene expression of Plasmodium falciparum require purification of RNAs from highly synchronized cultures. To date, no reliable method to control the quality of synchronization of P. falciparum cultures is available. METHODS: A double-staining method using hydroethidine and thiazole orange for nucleic acid staining was carried out to compare by flow cytometric analysis the nucleic acid labeling of synchronized P. falciparum in cultures at different time points of the 48-h intraerythrocytic cycle. RESULTS: With this method, we determined the quality of culture synchronization in schizont and ring stages. Nucleic acid analysis, based on thiazole orange fluorescence, clearly showed that low levels of schizonts in ring cultures results in a high contamination of ring nucleic acids by schizonts. Conversely, nucleic acids from trophozoite or schizont cultures containing ring stages did not present a significant contamination by ring nucleic acids. CONCLUSION: The results demonstrated a very low nucleic acid content in the ring stage when compared with the high nucleic acid content of schizont-stage parasites. The rapid and reliable flow cytometric strategy using hydroethidine- and thiazole orange-stained parasite nucleic acids allows monitoring of the purity of the preparation, thus greatly improving the quality assessment of parasite cultures, a critical step to study gene expression patterns.