Implementation of Bedaquiline, Pretomanid, and Linezolid in the United States: Experience Using a Novel All-Oral Treatment Regimen for Treatment of Rifampin-Resistant or Rifampin-Intolerant Tuberculosis Disease.

BACKGROUND: Rifampin-resistant tuberculosis is a leading cause of morbidity worldwide; only one-third of persons start treatment, and outcomes are often inadequate. Several trials demonstrate 90% efficacy using an all-oral, 6-month regimen of bedaquiline, pretomanid, and linezolid (BPaL), but significant toxicity occurred using 1200-mg linezolid. After US Food and Drug Administration approval in 2019, some US clinicians rapidly implemented BPaL using an initial 600-mg linezolid dose adjusted by serum drug concentrations and clinical monitoring. METHODS: Data from US patients treated with BPaL between 14 October 2019 and 30 April 2022 were compiled and analyzed by the BPaL Implementation Group (BIG), including baseline examination and laboratory, electrocardiographic, and clinical monitoring throughout treatment and follow-up. Linezolid dosing and clinical management was provider driven, and most patients had linezolid adjusted by therapeutic drug monitoring. RESULTS: Of 70 patients starting BPaL, 2 changed to rifampin-based therapy, 68 (97.1%) completed BPaL, and 2 of the 68 (2.9%) experienced relapse after completion. Using an initial 600-mg linezolid dose daily adjusted by therapeutic drug monitoring and careful clinical and laboratory monitoring for adverse effects, supportive care, and expert consultation throughout BPaL treatment, 3 patients (4.4%) with hematologic toxicity and 4 (5.9%) with neurotoxicity required a change in linezolid dose or frequency. The median BPaL duration was 6 months. CONCLUSIONS: BPaL has transformed treatment for rifampin-resistant or intolerant tuberculosis. In this cohort, effective treatment required less than half the duration recommended in 2019 US guidelines for drug-resistant tuberculosis. Use of individualized linezolid dosing and monitoring likely enhanced safety and treatment completion. The BIG cohort demonstrates that early implementation of new tuberculosis treatments in the United States is feasible.

A phenomenological approach shows a high coherence of warming patterns in dimictic aquatic systems across latitude.

To predict the coherence in local responses to large-scale climatic forcing among aquatic systems, we developed a generalized approach to compare long-term data of dimictic water bodies based on phenomenologically defined hydrographic events. These climate-sensitive phases (inverse stratification, spring overturn, early thermal stratification, summer stagnation) were classified in a dual code (cold/warm) based on threshold temperatures. Accounting for a latitudinal gradient in seasonal timing of phases derived from gradients in cumulative irradiation (2.2 days per degree latitude), we found a high spatial and temporal coherence in warm-cold patterns for six lakes (84 %) and the Baltic Sea (78 %), even when using the same thresholds for all sites. Similarity to CW-codes for the North Sea still was up to 72 %. The approach allows prediction of phase-specific warming trends and resulting instantaneous or time-delayed ecological responses. Exemplarily, we show that warming during early thermal stratification controls food-web-mediated effects on key species during summer.