Unpacking bedaquiline hetero-resistance: the importance of intermediate profiles for phenotypic drug-susceptibility testing

Phenotypic drug susceptibility testing (pDST) remains the gold standard for Mycobacterium tuberculosis complex drug resistance determination. Next generation sequencing technologies can identify heteroresistant populations at low frequencies, but little is known about the impact of heteroresistance on bedaquiline (BDQ) pDST results. We simulated heteroresistance using in vitro generated MmpR5 mutants mixed with the progenitor strain at various percentages (1-20%) and did pDST using MGIT960 culture (1 and 2 {micro}g/mL BDQ concentrations). Targeted Next Generation Sequencing (tNGS) was used to quantify the mutant sub-population in growth control tubes, which were expected to maintain the mutant: wild type proportion throughout the assay. Growth units of these growth control tubes were also comparable with minor differences in time-to-positivity between ratio mixtures. Only when intermediate results were considered could BDQ heteroresistance be detected at frequencies of approximately 1% by pDST at a critical concentration of 1 {micro}g/mL using BACTEC MGIT960 coupled with EpiCenter TBeXiST software. The ability of pDST, a widely available DST technique, to reveal the presence of BDQ-resistant subpopulations at the phenotypic testing stage could improve resistance determination and potentially reduce time to effective treatment. ImportanceMultidrug resistant tuberculosis (MDR-TB) is estimated to cause up to 19% of all antimicrobial resistance-attributable deaths worldwide. Further, the success rate for the treatment of drug-resistant TB, in the presence of adherence, is poor at only 68%. The advent of bedaquiline (BDQ) has revolutionized MDR-TB care, but BDQ resistance determination is hampered by several obstacles facing both phenotypic and genotypic testing. Specifically for phenotypic susceptibility testing, BDQ-resistant Mycobacterium tuberculosis isolates with variants in MmpR5, which may display minimal inhibitory concentration values just below the critical concentration or are present at low frequencies (heteroresistance; the presence of mixed mutant and wild-type populations within a specimen), are typically designated as susceptible. This may lead to prescription of an ineffective regimen and amplification of resistance. The BACTEC MGIT960 platform coupled with EpiCenter TBeXiST software for phenotypic testing, which is currently the only routinely used method of BDQ DST, can be used to derive more information about underlying resistant populations. We demonstrate how this is possible through the consideration of intermediate results (i.e., when growth units in a drug-containing tube reach the threshold for resistance but only after a further week of incubation). These intermediate results, commonly disregarded by TB laboratories, could lead to earlier detection of BDQ resistance. This is especially crucial when the genetic mechanism of resistance is unknown, a variant has not been associated with resistance in the interim, and in cases of heteroresistance.