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

Stefany Moreno-Gamez, Alison L. Hill, Daniel I. S. Rosenbloom, Dmitri A. Petrov, Martin A. Nowak, Pleuni Pennings
doi: https://doi.org/10.1101/013003
Stefany Moreno-Gamez
1Program for Evolutionary Dynamics, Department of Mathematics, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
2Centre for Ecological and Evolutionary Studies, University of Groningen, Groningen, 9747 AG, Netherlands
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Alison L. Hill
1Program for Evolutionary Dynamics, Department of Mathematics, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
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Daniel I. S. Rosenbloom
1Program for Evolutionary Dynamics, Department of Mathematics, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
3Department of Biomedical Informatics, Columbia University Medical Center, New York, NY 10032, USA
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Dmitri A. Petrov
4Department of Biology, Stanford University, Stanford, CA 94305, USA
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Martin A. Nowak
1Program for Evolutionary Dynamics, Department of Mathematics, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
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Pleuni Pennings
4Department of Biology, Stanford University, Stanford, CA 94305, USA
5Department of Biology, San Francisco State University, San Francisco, CA 94132, USA
6Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
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Abstract

Infections with rapidly evolving pathogens are often treated using combinations of drugs with different mechanisms of action. One of the major goals of combination therapy is to reduce the risk of drug resistance emerging during a patient’s treatment. While this strategy generally has significant benefits over monotherapy, it may also select for multi-drug resistant strains, which present an important clinical and public health problem. 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 multi-drug 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.

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The copyright holder for this preprint is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license.
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Posted December 19, 2014.
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Imperfect drug penetration leads to spatial monotherapy and rapid evolution of multi-drug resistance
Stefany Moreno-Gamez, Alison L. Hill, Daniel I. S. Rosenbloom, Dmitri A. Petrov, Martin A. Nowak, Pleuni Pennings
bioRxiv 013003; doi: https://doi.org/10.1101/013003
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Imperfect drug penetration leads to spatial monotherapy and rapid evolution of multi-drug resistance
Stefany Moreno-Gamez, Alison L. Hill, Daniel I. S. Rosenbloom, Dmitri A. Petrov, Martin A. Nowak, Pleuni Pennings
bioRxiv 013003; doi: https://doi.org/10.1101/013003

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